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The mission of The Basu Lab is to improve the ability of public health and healthcare systems to reduce the burden of preventable chronic diseases worldwide. We advance public health and healthcare delivery through community-based research, large-scale data analysis, and simulation modeling.

Clinical Trials

The EARN-Health Trial of Financial Savings and HealthNot Recruiting

The current literature in social epidemiology and public health suggests that low financial
savings has an unsurprising negative relationship with subjective well-being, and increases
the odds of making visits to a healthcare provider, receiving a chronic disease diagnosis,
and experiencing medical disability. Earn.org is a community-based non-profit based in San
Francisco with a mission to help low-income workers build lifelong savings habits and
financial capability. The organization is one of the largest providers of "goal-based savings
accounts" or "matched savings accounts" in the US. The investigators propose to conduct a
randomized controlled trial to determine the health effects of Earn's savings program.
Through this trial, the investigators will test three principal hypotheses: (1) Participants
in the Earn account, as compared to a control group, are hypothesized to demonstrate improved
scores on mental health scales assessing depression and anxiety.
(2) Participants in the Earn account, as compared to a control group, are hypothesized to
experience lower odds of harmful behaviors associated with stress, specifically tobacco and
alcohol abuse. The investigators hypothesize that the effect on behaviors will be of smaller
effect size, and more delayed, than the effect on mental health outcomes, judging from
similar effects observed in the micro-credit literature.
(3) The mediating variables between Earn account participation and beneficial health outcomes
will include increased optimism and internal locus of control.

Stanford is currently not accepting patients for this trial.For more information, please contact Sanjay Basu, (415) 881 - 7030.

Improving diets through increased food and vegetable (F&V) consumption significantly reduces
the risk of cardiovascular disease (CVD). Programs increasing the accessibility and
affordability of F&Vs among low-income Americans have been hindered by the food consumption
cycle associated with poverty: the tendency to over-consume calories shortly after receiving
funds at the beginning of each month, draining the budget for F&V purchases, or for all food
purchases, by month's end. An emerging theory about dietary behavior suggests that providing
funds for food in smaller installments distributed throughout the month will smooth the
consumption cycle and improve healthy eating?counteracting the tendency to respond to lump
sum, once-monthly funding installments by purchasing calorie-dense foods immediately after
funds are received. The theory also suggests that funds targeted toward specific healthy
foods (e.g., F&Vs) will improve diets more than untargeted funds, despite the inconvenience
of utilizing targeted funds. We will rigorously test both hypotheses in a real-world setting
by comparing alternative approaches for delivering food purchasing vouchers. We have
established and tested the infrastructure to provide vouchers accepted by numerous food
sellers (e.g., supermarkets, corner shops) in low-income neighborhoods. Leveraging this
infrastructure, we will conduct a randomized trial with a two-by-two factorial design,
comparing $20 of vouchers valid for one month to four $5 vouchers each valid for a sequential
week of the month (lump sum versus distributed funding), and comparing vouchers restricted to
F&V purchases to vouchers redeemable for any food (targeted versus untargeted funding).
Low-income adults (N=288) recruited through our community partners will be randomized to one
of four 6-month interventions: monthly targeted, monthly untargeted, weekly targeted, or
weekly untargeted vouchers. Participants will be assessed through efficient verbal 24-hour
dietary recalls validated among low-literacy populations, to determine daily consumption of
F&Vs and metrics of overall dietary quality at months 0, 6 and 12 (6 months after vouchers
end). Additional surveys will identify moderators and mediators of dietary improvement.

Stanford is currently not accepting patients for this trial.For more information, please contact Sanjay Basu, (415) 881 - 7030.

Publications

All Publications

Abstract

The aim of this study was to review and assess the evidence for low-density lipoprotein cholesterol (LDL-C) treatment goals as presented in current guidelines for primary and secondary prevention of cardiovascular disease.Different sets of guidelines and clinical studies for secondary prevention have centered on lower absolute LDL-C targets [<70 mg/dL (<1.8 mmol/L)], greater percent reductions of LDL-C (?50%), or more intense treatment to achieve greater reductions in cardiovascular risk. Population-based risk models serve as the basis for statin initiation in primary prevention. Reviews of current population risk models for primary prevention show moderate ability to discriminate [with c-statistics ranging from 0.67 to 0.77 (95% CIs from 0.62 to 0.83) for men and women] with poor calibration and overestimation of risk. Individual clinical trial data are not compelling to support specific LDL-C targets and percent reductions in secondary prevention. Increasing utilization of electronic health records and data analytics will enable the development of individualized treatment goals in both primary and secondary prevention.

Abstract

Regional trade agreements are major international policy instruments that shape macro-economic and political systems. There is widespread debate as to whether and how these agreements pose risks to public health. Here we perform a comprehensive systematic review of quantitative studies of the health impact of trade and investment agreements. We identified studies from searches in PubMed, Web of Science, EMBASE, and Global Health Online. Research articles were eligible for inclusion if they were quantitative studies of the health impacts of trade and investment agreements or policy. We systematically reviewed study findings, evaluated quality using the Quality Assessment Tool from the Effective Public Health Practice Project, and performed network citation analysis to study disciplinary siloes.Seventeen quantitative studies met our inclusion criteria. There was consistent evidence that implementing trade agreements was associated with increased consumption of processed foods and sugar-sweetened beverages. Granting import licenses for patented drugs was associated with increased access to pharmaceuticals. Implementing trade agreements and associated policies was also correlated with higher cardiovascular disease incidence and higher Body Mass Index (BMI), whilst correlations with tobacco consumption, under-five mortality, maternal mortality, and life expectancy were inconclusive. Overall, the quality of studies is weak or moderately weak, and co-citation analysis revealed a relative isolation of public health from economics.We identified limitations in existing studies which preclude definitive conclusions of the health impacts of regional trade and investment agreements. Few address unobserved confounding, and many possible consequences and mechanisms linking trade and investment agreements to health remain poorly understood. Results from our co-citation analysis suggest scope for greater interdisciplinary collaboration. Notwithstanding these limitations, our results find evidence that trade agreements pose some significant health risks. Health protections in trade and investment treaties may mitigate these impacts.

Abstract

Uncertainty about the financial costs and benefits of community health worker (CHW) programs remains a barrier to their adoption.To determine how much CHWs would need to reduce emergency department (ED) visits and associated hospitalizations among their assigned patients to be cost-neutral from a payer's perspective.Using a microsimulation of patient health care utilization, costs, and revenues, we estimated what portion of ED visits and hospitalizations for different conditions would need to be prevented by a CHW program to fully pay for the program's expenses. The model simulated CHW programs enrolling patients with a history of at least 1 ED visit for a chronic condition in the prior year, utilizing data on utilization and cost from national sources.CHWs assigned to patients with uncontrolled hypertension and congestive heart failure, as compared with other common conditions, achieve cost-neutrality with the lowest number of averted visits to the ED. To achieve cost-neutrality, 4-5 visits to the ED would need to be averted per year by a CHW assigned a panel of 70 patients with uncontrolled hypertension or congestive heart failure-approximately 3%-4% of typical ED visits among such patients, respectively. Most other chronic conditions would require between 7% and 12% of ED visits to be averted to achieve cost-savings.Offsetting costs of a CHW program is theoretically feasible for many common conditions. Yet the benchmark for reducing ED visits and associated hospitalizations varies substantially by a patient's primary diagnosis.

Abstract

A diet high in fruits and vegetables (FV) is associated with reduced risk of chronic disease. One strategy to incentivize FV consumption among low-income households is to make them more affordable through the Supplemental Nutrition Assistance Program (SNAP). This study aims to identify the cost effectiveness of subsidizing FV purchases among the one in seven Americans who participate in SNAP.A cost-effectiveness analysis was conducted from a societal perspective to estimate lifetime costs and health gains associated with subsidizing FV purchases. A stochastic microsimulation model of obesity, type 2 diabetes, myocardial infarction, and stroke in the 2015 U.S. population was used. Model parameters were based on nationally representative SNAP participation and dietary consumption data from the National Health and Nutrition Examination Survey (2003-2012), and data from a randomized trial of FV subsidies among SNAP users.Despite cycling of participants in and out of SNAP, expanding an FV subsidy nationwide through SNAP would be expected to reduce incidence of type 2 diabetes by 1.7% (95% CI=1.2, 2.2), myocardial infarction by 1.4% (95% CI=0.9, 1.9), stroke by 1.2% (95% CI=0.8, 1.6), and obesity by 0.2% (95% CI=0.1, 0.3), and be cost saving from a societal perspective. The saved costs would be largely attributable to long-term reductions in type 2 diabetes and cardiovascular diseases.The model suggests nationwide SNAP FV subsidies would reduce chronic disease morbidity, mortality, and costs over long time horizons that are unlikely to be observed in short-term community-based trials.

Abstract

Optimal prescription of blood pressure, lipid, and glycaemic control treatments for adults with type 2 diabetes remains unclear. We aimed to compare the effectiveness and cost-effectiveness of two treatment approaches for diabetes management in five low-income and middle-income countries.We developed a microsimulation model to compare a treat-to-target (TTT) strategy, aiming to achieve target levels of biomarkers (blood pressure <130/80 mm Hg, LDL <2·59 mmol/L, and HbA1c <7% [ie, 53·0 mmol/mol]), with a benefit-based tailored treatment (BTT) strategy, aiming to lower estimated risk for complications (to a 10 year cardiovascular risk <10% and lifetime microvascular risk <5%) on the basis of age, sex, and biomarker values. Data were obtained from cohorts in China, Ghana, India, Mexico, and South Africa to span a spectrum of risk profiles.The TTT strategy recommended treatment to a larger number of people-who were generally at lower risk of diabetes complications-than the BTT. The BTT strategy recommended treatment to fewer people at higher risk. Compared with the TTT strategy, the BTT strategy would be expected to avert 24·4-30·5% more complications and be more cost-effective from a societal perspective (saving US$4·0-300·0 per disability-adjusted life-year averted in the countries simulated). Alternative treatment thresholds, matched by total cost or population size treated, did not change the comparative superiority of the BTT strategy, nor did titrating treatment using fasting plasma glucose (for areas without HbA1c testing). However, if insulin were unavailable, the BTT strategy would no longer be superior for preventing microvascular events and was superior only for preventing cardiovascular events.A BTT strategy is more effective and cost-effective than a TTT strategy in low-income and middle-income countries for prevention of both cardiovascular and microvascular complications of type 2 diabetes. However, the superiority of the BTT strategy for averting microvascular complications is contingent on insulin availability.Rosenkranz Prize for Healthcare Research in Developing Countries and US National Institutes of Health (U54 MD010724, DP2 MD010478).

Moderation of the Relation of County-Level Cost of Living to Nutrition by the Supplemental Nutrition Assistance ProgramAMERICAN JOURNAL OF PUBLIC HEALTHBasu, S., Wimer, C., Seligman, H.2016; 106 (11): 2064-2070

Abstract

To examine the association of county-level cost of living with nutrition among low-income Americans.We used the National Household Food Acquisition and Purchase Survey (2012-2013; n?=?14?313; including 5414 persons in households participating in the Supplemental Nutrition Assistance Program [SNAP]) to examine associations between county-level cost-of-living metrics and both food acquisitions and the Healthy Eating Index, with control for individual-, household-, and county-level covariates and accounting for unmeasured confounders influencing both area of living and food acquisition.Living in a higher-cost county-particularly one with high rent costs-was associated with significantly lower volume of acquired vegetables, fruits, and whole grains; greater volume of acquired refined grains, fats and oils, and added sugars; and an 11% lower Healthy Eating Index score. Participation in SNAP was associated with nutritional improvements among persons living in higher-cost counties.Living in a higher-cost county (particularly with high rent costs) is associated with poorer nutrition among low-income Americans, and SNAP may mitigate the negative nutritional impact of high cost of living.

Abstract

In September, 2015, the UN General Assembly established the Sustainable Development Goals (SDGs). The SDGs specify 17 universal goals, 169 targets, and 230 indicators leading up to 2030. We provide an analysis of 33 health-related SDG indicators based on the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015).We applied statistical methods to systematically compiled data to estimate the performance of 33 health-related SDG indicators for 188 countries from 1990 to 2015. We rescaled each indicator on a scale from 0 (worst observed value between 1990 and 2015) to 100 (best observed). Indices representing all 33 health-related SDG indicators (health-related SDG index), health-related SDG indicators included in the Millennium Development Goals (MDG index), and health-related indicators not included in the MDGs (non-MDG index) were computed as the geometric mean of the rescaled indicators by SDG target. We used spline regressions to examine the relations between the Socio-demographic Index (SDI, a summary measure based on average income per person, educational attainment, and total fertility rate) and each of the health-related SDG indicators and indices.In 2015, the median health-related SDG index was 59·3 (95% uncertainty interval 56·8-61·8) and varied widely by country, ranging from 85·5 (84·2-86·5) in Iceland to 20·4 (15·4-24·9) in Central African Republic. SDI was a good predictor of the health-related SDG index (r(2)=0·88) and the MDG index (r(2)=0·92), whereas the non-MDG index had a weaker relation with SDI (r(2)=0·79). Between 2000 and 2015, the health-related SDG index improved by a median of 7·9 (IQR 5·0-10·4), and gains on the MDG index (a median change of 10·0 [6·7-13·1]) exceeded that of the non-MDG index (a median change of 5·5 [2·1-8·9]). Since 2000, pronounced progress occurred for indicators such as met need with modern contraception, under-5 mortality, and neonatal mortality, as well as the indicator for universal health coverage tracer interventions. Moderate improvements were found for indicators such as HIV and tuberculosis incidence, minimal changes for hepatitis B incidence took place, and childhood overweight considerably worsened.GBD provides an independent, comparable avenue for monitoring progress towards the health-related SDGs. Our analysis not only highlights the importance of income, education, and fertility as drivers of health improvement but also emphasises that investments in these areas alone will not be sufficient. Although considerable progress on the health-related MDG indicators has been made, these gains will need to be sustained and, in many cases, accelerated to achieve the ambitious SDG targets. The minimal improvement in or worsening of health-related indicators beyond the MDGs highlight the need for additional resources to effectively address the expanded scope of the health-related SDGs.Bill & Melinda Gates Foundation.

Abstract

Globally, tuberculosis prevalence has declined, but its risk factors have varied across place and time - low body mass index (BMI) has persisted while diabetes has increased. Using India's National Family Health Survey (NFHS), wave 3 and World Health Survey (WHS) data, we examined their relationships to support projection of future trends and targeted control efforts.Multivariate logistic regressions at the individual level with and without diabetes/BMI interactions assessed the relationship between tuberculosis, diabetes and low BMI and the importance of risk factor co-occurrence. Population-level analyses examined how tuberculosis incidence and prevalence varied with diabetes/low BMI co-occurrence.In NFHS, diabetic individuals had higher predicted tuberculosis risks (diabetic vs. non-diabetic: 2.50% vs. 0.63% at low BMI; 0.81% vs. 0.20% at normal BMI; 0.37% vs. 0.09% at high BMI), which were not significantly different when modelled independently or allowing for risk modification with diabetes/low BMI co-occurrence. WHS findings were generally consistent. Population-level analysis found that diabetes/low BMI co-occurrence may be associated with elevated tuberculosis risk, although its predicted effect on tuberculosis incidence/prevalence was generally ?0.2 percentage points and not robustly statistically significant.Concerns about the additional elevation of tuberculosis risk from diabetes/low BMI co-occurrence and hence the need to coordinate tuberculosis control efforts around the nexus of co-occurring diabetes and low BMI may be premature. However, study findings robustly support the importance of individually targeting low BMI and diabetes as part of ongoing tuberculosis control efforts.

Abstract

Although studies have shown associations between neighbourhood quality and chronic disease outcomes, such associations are potentially confounded by the selection of different types of people into different neighbourhood environments. We sought to identify the causal effects of neighbourhood deprivation on type 2 diabetes risk, by comparing refugees in Sweden who were actively dispersed by government policy to low-deprivation, moderate-deprivation, or high-deprivation neighbourhoods.In this quasi-experimental study, we analysed national register data for refugees who arrived in Sweden aged 25-50 years, at a time when the government policy involved quasi-random dispersal of refugees to neighbourhoods with different levels of poverty and unemployment, schooling, and social welfare participation. Individuals in our sample were assigned to a neighbourhood categorised as high deprivation (?1 SD above the mean), moderate deprivation (within 1 SD of the mean), or low deprivation (?1 SD below the mean). The primary outcome was new diagnosis of type 2 diabetes between Jan 1, 2002, and Dec 31, 2010. We used multivariate logistic and linear regressions to assess the effects of neighbourhood deprivation on diabetes risk, controlling for potential confounders affecting neighbourhood assignment and assessing effects of cumulative exposure to different neighbourhood conditions.We included data for 61?386 refugees who arrived in Sweden during 1987-91 and who were assigned to one of 4833 neighbourhoods. Being assigned to an area deemed high deprivation versus low deprivation was associated with an increased risk of diabetes (odds ratio [OR] 1·22, 95% CI 1·07-1·38; p=0·001). In analyses that included fixed effects for assigned municipality, the increased diabetes risk was estimated to be 0·85 percentage points (95% CI -0·030 to 1·728; p=0·058). Neighbourhood effects grew over time such that 5 years of additional exposure to high-deprivation versus low-deprivation neighbourhoods was associated with a 9% increase in diabetes risk.This study makes use of a pre-existing governmental natural experiment to show that neighbourhood deprivation increased the risk of diabetes in refugees in Sweden. This finding has heightened importance in the context of the current refugee crisis in Europe.US National Heart, Lung, and Blood Institute, US National Center for Advancing Translational Sciences, US National Institute on Minority Health and Health Disparities, Swedish Research Council.

Abstract

The World Health Organization aims to reduce mortality from chronic diseases including cardiovascular disease (CVD) by 25% by 2025. High blood pressure is a leading CVD risk factor. We sought to compare 3 strategies for treating blood pressure in China and India: a treat-to-target (TTT) strategy emphasizing lowering blood pressure to a target, a benefit-based tailored treatment (BTT) strategy emphasizing lowering CVD risk, or a hybrid strategy currently recommended by the World Health Organization.We developed a microsimulation model of adults aged 30 to 70 years in China and in India to compare the 2 treatment approaches across a 10-year policy-planning horizon. In the model, a BTT strategy treating adults with a 10-year CVD event risk of ?10% used similar financial resources but averted ?5 million more disability-adjusted life-years in both China and India than a TTT approach based on current US guidelines. The hybrid strategy in the current World Health Organization guidelines produced no substantial benefits over TTT. BTT was more cost-effective at $205 to $272/disability-adjusted life-year averted, which was $142 to $182 less per disability-adjusted life-year than TTT or hybrid strategies. The comparative effectiveness of BTT was robust to uncertainties in CVD risk estimation and to variations in the age range analyzed, the BTT treatment threshold, or rates of treatment access, adherence, or concurrent statin therapy.In model-based analyses, a simple BTT strategy was more effective and cost-effective than TTT or hybrid strategies in reducing mortality.

Abstract

. The National Salt Reduction Initiative, in which food producers agree to lower sodium to levels deemed feasible for different foods, is expected to significantly reduce sodium intake if expanded to a large sector of food manufacturers.. Given recent data on the relationship between sodium intake, hypertension, and associated cardiovascular disease at a population level, we sought to examine risks and benefits of the program.. To estimate the impact of further expanding the initiative on hypertension, myocardial infarction (MI) and stroke incidence, and related mortality, given food consumption patterns across the United States, we developed and validated a stochastic microsimulation model of hypertension, MI, and stroke morbidity and mortality, using data from food producers on sodium reduction among foods, linked to 24-hour dietary recalls, blood pressure, and cardiovascular histories from the National Health and Nutrition Examination Survey.. Expansion of the initiative to ensure all restaurants and manufacturers reach agreed-upon sodium targets would be expected to avert from 0.9 to 3.0 MIs (a 1.6%-5.4% reduction) and 0.5 to 2.8 strokes (a 1.1%-6.2% reduction) per 10,000 Americans per year over the next decade, after incorporating consumption patterns and variations in the effect of sodium reduction on blood pressure among different demographic groups. Even high levels of consumer addition of table salt or substitution among food categories would be unlikely to neutralize this benefit. However, if recent epidemiological associations between very low sodium and increased mortality are causal, then older women may be at risk of increased mortality from excessively low sodium intake.An expanded National Salt Reduction Initiative is likely to significantly reduce hypertension and hypertension-related cardiovascular morbidity but may be accompanied by potential risks to older women.

Using Decomposition Analysis to Identify Modifiable Racial Disparities in the Distribution of Blood Pressure in the United StatesAMERICAN JOURNAL OF EPIDEMIOLOGYBasu, S., Hong, A., Siddiqi, A.2015; 182 (4): 345-353

Abstract

To lower the prevalence of hypertension and racial disparities in hypertension, public health agencies have attempted to reduce modifiable risk factors for high blood pressure, such as excess sodium intake or high body mass index. In the present study, we used decomposition methods to identify how population-level reductions in key risk factors for hypertension could reshape entire population distributions of blood pressure and associated disparities among racial/ethnic groups. We compared blood pressure distributions among non-Hispanic white, non-Hispanic black, and Mexican-American persons using data from the US National Health and Nutrition Examination Survey (2003-2010). When using standard adjusted logistic regression analysis, we found that differences in body mass index were the only significant explanatory correlate to racial disparities in blood pressure. By contrast, our decomposition approach provided more nuanced revelations; we found that disparities in hypertension related to tobacco use might be masked by differences in body mass index that significantly increase the disparities between black and white participants. Analysis of disparities between white and Mexican-American participants also reveal hidden relationships between tobacco use, body mass index, and blood pressure. Decomposition offers an approach to understand how modifying risk factors might alter population-level health disparities in overall outcome distributions that can be obscured by standard regression analyses.

Abstract

Global food prices have risen sharply since 2007. The impact of food price spikes on the risk of malnutrition in children is not well understood.We investigated the associations between food price spikes and childhood malnutrition in Andhra Pradesh, one of India's largest states, with >85 million people. Because wasting (thinness) indicates in most cases a recent and severe process of weight loss that is often associated with acute food shortage, we tested the hypothesis that the escalating prices of rice, legumes, eggs, and other staples of Indian diets significantly increased the risk of wasting (weight-for-height z scores) in children.We studied periods before (2006) and directly after (2009) India's food price spikes with the use of the Young Lives longitudinal cohort of 1918 children in Andhra Pradesh linked to food price data from the National Sample Survey Office. Two-stage least squares instrumental variable models assessed the relation of food price changes to food consumption and wasting prevalence (weight-for-height z scores).Before the 2007 food price spike, wasting prevalence fell from 19.4% in 2002 to 18.8% in 2006. Coinciding with India's escalating food prices, wasting increased significantly to 28.0% in 2009. These increases were concentrated among low- (?(2): 21.6, P < 0.001) and middle- (?(2): 25.9, P < 0.001) income groups, but not among high-income groups (?(2): 3.08, P = 0.079). Each 10.0 rupee ($0.170) increase in the price of rice/kg was associated with a drop in child-level rice consumption of 73.0 g/d (?: -7.30; 95% CI: -10.5, -3.90). Correspondingly, lower rice consumption was significantly associated with lower weight-for-height z scores (i.e., wasting) by 0.005 (95% CI: 0.001, 0.008), as seen with most other food categories.Rising food prices were associated with an increased risk of malnutrition among children in India. Policies to help ensure the affordability of food in the context of economic growth are likely critical for promoting children's nutrition.

What do Indian children drink when they do not receive water? Statistical analysis of water and alternative beverage consumption from the 2005-2006 Indian National Family Health SurveyBMC PUBLIC HEALTHFledderjohann, J., Doyle, P., Campbell, O., Ebrahim, S., Basu, S., Stuckler, D.2015; 15

Abstract

Over 1.2 billion people lack access to clean water. However, little is known about what children drink when there is no clean water. We investigated the prevalence of receiving no water and what Indian children drink instead.We analysed children's beverage consumption using representative data from India's National Family and Health Survey (NFHS-3, 2005-2006). Consumption was based on mothers' reports (n?=?22,668) for children aged 6-59 months (n?=?30,656).About 10 % of Indian children had no water in the last 24 h, corresponding to 12,700,000 children nationally, (95 % CI: 12,260,000 to 13,200,000). Among children who received no water, 23 % received breast or fresh milk and 24 % consumed formula, "other liquid", juice, or two or more beverages. Children over 2 were more likely to consume non-milk beverages, including tea, coffee, and juice than those under 2 years. Those in the lowest two wealth quintiles were 16 % less likely to have received water (OR?=?0.84; 95 % CI: 0.74 to 0.96). Compared to those living in households with bottled, piped, or tanker water, children were significantly less likely to receive water in households using well water (OR?=?0.75; 95 % CI: 0.64 to 0.89) or river, spring, or rain water (OR?=?0.70; 95 % CI: 0.53 to 0.92) in the last 24 h.About 13 million Indian children aged 6-59 months received no water in the last 24 h. Further research is needed to assess the risks potentially arising from insufficient water, caffeinated beverages, and high sugar drinks at early stages of life.

Abstract

During the 2007-11 recessions in Europe, suicide increases were concentrated in men. Substantial differences across countries and over time remain unexplained. We investigated whether increases in unaffordable housing, household indebtedness or job loss can account for these population differences, as well as potential mitigating effects of alternative forms of social protection.Multivariate statistical models were used to evaluate changes in suicide rates in 20 EU countries from 1981-2011. Models adjusted for pre-existing time trends and country-fixed effects. Interaction terms were used to evaluate modifying effects.Changes in levels of unaffordable housing had no effect on suicide rates (P = 0.32); in contrast, male suicide increases were significantly associated with each percentage point rise in male unemployment, by 0.94% (95% CI: 0.51-1.36%), and indebtedness, by 0.54% (95% CI: 0.02-1.06%). Spending on active labour market programmes (ALMP) (-0.26%, 95% CI: -0.08 to -0.45%) and high levels of social capital (-0.048%, 95% CI: -0.0096 to -0.087) moderated the unemployment-suicide association. There was no interaction of the volume of anti-depressant prescriptions (P = 0.51), monetary benefits to unemployed persons (P = 0.77) or total social protection spending per capita (P = 0.37). Active labour market programmes and social capital were estimated to have prevented ? 540 and ? 210 male suicides, respectively, arising from unemployment in the countries studied.Job losses were a critical determinant of variations in male suicide risks in Europe's recessions. Greater spending on ALMP and levels of social capital appeared to mitigate suicide risks.

Abstract

Like a growing number of rapidly developing countries, India has begun to develop a system for large-scale community-based screening for diabetes. We sought to identify the implications of using alternative screening instruments to detect people with undiagnosed type 2 diabetes among diverse populations across India.We developed and validated a microsimulation model that incorporated data from 58 studies from across the country into a nationally representative sample of Indians aged 25-65 y old. We estimated the diagnostic and health system implications of three major survey-based screening instruments and random glucometer-based screening. Of the 567 million Indians eligible for screening, depending on which of four screening approaches is utilized, between 158 and 306 million would be expected to screen as "high risk" for type 2 diabetes, and be referred for confirmatory testing. Between 26 million and 37 million of these people would be expected to meet international diagnostic criteria for diabetes, but between 126 million and 273 million would be "false positives." The ratio of false positives to true positives varied from 3.9 (when using random glucose screening) to 8.2 (when using a survey-based screening instrument) in our model. The cost per case found would be expected to be from US$5.28 (when using random glucose screening) to US$17.06 (when using a survey-based screening instrument), presenting a total cost of between US$169 and US$567 million. The major limitation of our analysis is its dependence on published cohort studies that are unlikely fully to capture the poorest and most rural areas of the country. Because these areas are thought to have the lowest diabetes prevalence, this may result in overestimation of the efficacy and health benefits of screening.Large-scale community-based screening is anticipated to produce a large number of false-positive results, particularly if using currently available survey-based screening instruments. Resource allocators should consider the health system burden of screening and confirmatory testing when instituting large-scale community-based screening for diabetes.

Abstract

Tuberculosis (TB) remains disproportionately concentrated among the poor, yet known determinants of TB reactivation may fail to explain observed disparities in disease rates according to wealth. Reviewing data on TB disparities in India and the wealth distribution of known TB risk factors, we describe how social mixing patterns could be contributing to TB disparities. Wealth-assortative mixing, whereby individuals are more likely to be in contact with others from similar socio-economic backgrounds, amplifies smaller differences in risk of TB, resulting in large population-level disparities. As disparities and assortativeness increase, TB becomes more difficult to control, an effect that is obscured by looking at population averages of epidemiological parameters, such as case detection rates. We illustrate how TB control efforts may benefit from preferential targeting toward the poor. In India, an equivalent-scale intervention could have a substantially greater impact if targeted at those living below the poverty line than with a population-wide strategy. In addition to potential efficiencies in targeting higher-risk populations, TB control efforts would lead to a greater reduction in secondary TB cases per primary case diagnosed if they were preferentially targeted at the poor. We highlight the need to collect programmatic data on TB disparities and explicitly incorporate equity considerations into TB control plans.

Abstract

The use of self-reported measures of chronic disease may substantially underestimate prevalence in low-income and middle-income country settings, especially in groups with lower socioeconomic status (SES). We sought to determine whether socioeconomic inequalities in the prevalence of non-communicable chronic diseases (NCDs) differ if estimated by using symptom-based or criterion-based measures compared with self-reported physician diagnoses.Using population-representative data sets of the WHO Study of Global Ageing and Adult Health (SAGE), 2007-2010 (n=42?464), we calculated wealth-related and education-related concentration indices of self-reported diagnoses and symptom-based measures of angina, hypertension, asthma/chronic lung disease, visual impairment and depression in three 'low-income and lower middle-income countries'-China, Ghana and India-and three 'upper-middle-income countries'-Mexico, Russia and South Africa.SES gradients in NCD prevalence tended to be positive for self-reported diagnoses compared with symptom-based/criterion-based measures. In China, Ghana and India, SES gradients were positive for hypertension, angina, visual impairment and depression when using self-reported diagnoses, but were attenuated or became negative when using symptom-based/criterion-based measures. In Mexico, Russia and South Africa, this distinction was not observed consistently. For example, concentration index of self-reported versus symptom-based angina were: in China: 0.07 vs -0.11, Ghana: 0.04 vs -0.21, India: 0.02 vs -0.16, Mexico: 0.19 vs -0.22, Russia: -0.01 vs -0.02 and South Africa: 0.37 vs 0.02.Socioeconomic inequalities in NCD prevalence tend to be artefactually positive when using self-report compared with symptom-based or criterion-based diagnostic criteria, with greater bias occurring in low-income countries. Using standardised, symptom-based measures would provide more valid estimates of NCD inequalities.

Abstract

Analyzing news media allows obesity policy researchers to understand popular conceptions about obesity, which is important for targeting health education and policies. A persistent dilemma is that investigators have to read and manually classify thousands of individual news articles to identify how obesity and obesity-related policy proposals may be described to the public in the media. A machine learning method called "automated content analysis" that permits researchers to train computers to "read" and classify massive volumes of documents was demonstrated.14,302 newspaper articles that mentioned the word "obesity" during 2011-2012 were identified. Four states that vary in obesity prevalence and policy (Alabama, California, New Jersey, and North Carolina) were examined. The reliability of an automated program to categorize the media's framing of obesity as an individual-level problem (e.g., diet) and/or an environmental-level problem (e.g., obesogenic environment) was tested.The automated program performed similarly to human coders. The proportion of articles with individual-level framing (27.7-31.0%) was higher than the proportion with neutral (18.0-22.1%) or environmental-level framing (16.0-16.4%) across all states and over the entire study period (P<0.05).A novel approach to the study of how obesity concepts are communicated and propagated in news media was demonstrated.

Abstract

It is uncertain whether the inverse equity hypothesis-the idea that new health interventions are initially primarily accessed by the rich, but that inequalities narrow with diffusion to the poor-holds true for cancer screening in low and middle income countries (LMICs).This study examines the relationship between overall coverage and economic inequalities in coverage of cancer screening in four middle-income countries.Secondary analyses of cross-sectional data from the WHO study on Global Ageing and Adult Health in China, Mexico, Russia and South Africa (2007-2010). Three regression-based methods were used to measure economic inequalities: (1) Adjusted OR; (2) Relative Index of Inequality (RII); and (3) Slope Index of Inequality.Coverage for breast cancer screening was 10.5% in South Africa, 19.3% in China, 33.8% in Russia and 43% in Mexico, and coverage for cervical cancer screening was 24% in South Africa, 27.2% in China, 63.7% in Mexico and 81.5% in Russia. Economic inequalities in screening participation were substantially lower or non-existent in countries with higher aggregate coverage, for both breast cancer screening (RII: 14.57 in South Africa, 4.90 in China, 2.01 in Mexico, 1.04 in Russia) and cervical cancer screening (RII: 3.60 in China, 2.47 in South Africa, 1.39 in Mexico, 1.12 in Russia).Economic inequalities in breast and cervical cancer screening are low in LMICs with high screening coverage. These findings are consistent with the inverse equity hypothesis and indicate that high levels of equity in cancer screening are feasible even in countries with high income inequality.

Abstract

Primary care practice transformations require tools for policymakers and practice managers to understand the financial implications of workforce and reimbursement changes.To create a simulation model to understand how practice utilization, revenues, and expenses may change in the context of workforce and financing changes.We created a simulation model estimating clinic-level utilization, revenues, and expenses using user-specified or public input data detailing practice staffing levels, salaries and overhead expenditures, patient characteristics, clinic workload, and reimbursements. We assessed whether the model could accurately estimate clinic utilization, revenues, and expenses across the nation using labor compensation, medical expenditure, and reimbursements databases, as well as cost and revenue data from independent practices of varying size. We demonstrated the model's utility in a simulation of how utilization, revenue, and expenses would change after hiring a nurse practitioner (NP) compared with hiring a part-time physician.Modeled practice utilization and revenue closely matched independent national utilization and reimbursement data, disaggregated by patient age, sex, race/ethnicity, insurance status, and ICD diagnostic group; the model was able to estimate independent revenue and cost estimates, with highest accuracy among larger practices. A demonstration analysis revealed that hiring an NP to work independently with a subset of patients diagnosed with diabetes or hypertension could increase net revenues, if NP visits involve limited MD consultation or if NP reimbursement rates increase.A model of utilization, revenue, and expenses in primary care practices may help policymakers and managers understand the implications of workforce and financing changes.

Abstract

Demographic and socioeconomic changes such as increasing urbanization, migration, and female education shape population health in many low- and middle-income countries. These changes are rarely reflected in computational epidemiological models, which are commonly used to understand population health trends and evaluate policy interventions. Our goal was to create a "backbone" simulation modeling approach to allow computational epidemiologists to explicitly reflect changing demographic and socioeconomic conditions in population health models.We developed, evaluated, and "open-sourced" a generalized approach to incorporate longitudinal, commonly available demographic and socioeconomic data into epidemiological simulations, illustrating the feasibility and utility of our approach with data from India. We constructed a series of nested microsimulations of increasing complexity, calibrating each model to longitudinal sociodemographic and vital registration data. We then selected the model that was most consistent with the data (i.e., greater accuracy) while containing the fewest parameters (i.e., greater parsimony). We validated the selected model against additional data sources not used for calibration.We found that standard computational epidemiology models that do not incorporate demographic and socioeconomic trends quickly diverged from past mortality and population size estimates, while our approach remained consistent with observed data over decadal time courses. Our approach additionally enabled the examination of complex relations between demographic, socioeconomic and health parameters, such as the relationship between changes in educational attainment or urbanization and changes in fertility, mortality, and migration rates.Incorporating demographic and socioeconomic trends in computational epidemiology is feasible through the "open source" approach, and could critically alter population health projections and model-based evaluations of health policy interventions in unintuitive ways.

Abstract

A theory within the social epidemiology field is that financial stress related to having inadequate financial savings may contribute to psychological stress, poor mental health and poor health-related behaviours among low-income US adults. Our objective is to test whether an intervention that encourages financial savings among low-income US adults improves health behaviours and mental health.A parallel group two-arm controlled superiority trial will be performed in which 700 participants will be randomised to the intervention or a wait list. The intervention arm will be provided an online Individual Development Account (IDA) for 6?months, during which participants receive a $5 incentive (£3.2, ?4.5) for every month they save $20 in their account (£12.8, ?18), and an additional $5 if they save $20 for two consecutive months. Both groups will be provided links to standard online financial counselling materials. Online surveys in months 0 (prior to randomisation), 6 and 12 (6?months postintervention) will assess self-reported health behaviours and mental health among participants in both arms. The surveys items were tested previously in the US Centers for Disease Control and Prevention national health interviews and related health studies, including self-reported overall health, health-related quality of life, alcohol and tobacco use, depression symptoms, financial stress, optimism and locus of control, and spending and savings behaviours. Trial data will be analysed on an intent-to-treat basis.This protocol was approved by the Institutional Review Board of Stanford University (Protocol ID: 30641). The findings of the trial will be disseminated through peer-reviewed publication.Identifier NCT02185612; Pre-results.

Abstract

We estimated the effect of a simulated cap-and-trade policy to reduce added sugar in the food supply.Using nationally representative data on added-sugar content and consumption, we constructed a mathematical model of a cap-and-trade policy and compared its health implications to those of proposals to tax sugar sweetened beverages or added sugars.Capping added-sugar emissions into the food supply by food manufacturers at a rate of 1% per year would be expected to reduce the prevalence of obesity by 1.7 percentage points (95% confidence interval [CI]?=?0.9, 2.4; a 4.6% decline) and the incidence of type 2 diabetes by 21.7 cases per 100?000 people (95% CI?=?12.9, 30.6; a 4.2% decline) over 20 years, averting approximately $9.7 billion in health care spending. Racial and ethnic minorities would be expected to experience the largest declines. By comparison, equivalent price penalties through excise taxes would be expected to generate smaller health benefits.A cap-and-trade policy to reduce added-sugar intake may reduce obesity and type 2 diabetes to a greater extent than currently-proposed excise taxes.

Abstract

To examine whether late-career job loss increased depression among older workers approaching retirement in the USA and Europe.Longitudinal data came from the Health and Retirement Survey and the Survey of Health, Ageing, and Retirement in Europe. Workers aged 50 to 64 years in 13 European countries and the USA were assessed biennially from 2006 to 2010. Individual fixed effects models were used to test the effect of job loss on depressive symptoms, controlling for age, sex, physical health, initial wealth and socio-demographic factors.Job loss was associated with a 4.78% [95% confidence interval (CI): 0.823% to 8.74%] increase in depressive symptoms in the USA compared with a 3.35% (95% CI: 0.486% to 6.22%) increase in Europe. Job loss due to a worker's unexpected firm closure increased depression scores in both the USA (beta=28.2%, 95% CI: 8.55% to 47.8%) and Europe (beta=7.50%, 95% CI: 1.25% to 13.70%), but pooled models suggested significantly stronger effects for US workers (P<0.001). American workers who were poorer before the recession experienced significantly larger increases in depressive symptoms compared with wealthier US workers (beta for interaction=-0.054, 95% CI: -0.082 to -0.025), whereas pre-existing wealth did not moderate the impact of job loss among European workers.Job loss is associated with increased depressive symptoms in the USA and Europe, but effects of job loss due to plant closure are stronger for American workers. Wealth mitigates the impact of job loss on depression in the USA more than in Europe.

Abstract

The Millennium Declaration in 2000 brought special global attention to HIV, tuberculosis, and malaria through the formulation of Millennium Development Goal (MDG) 6. The Global Burden of Disease 2013 study provides a consistent and comprehensive approach to disease estimation for between 1990 and 2013, and an opportunity to assess whether accelerated progress has occured since the Millennium Declaration.To estimate incidence and mortality for HIV, we used the UNAIDS Spectrum model appropriately modified based on a systematic review of available studies of mortality with and without antiretroviral therapy (ART). For concentrated epidemics, we calibrated Spectrum models to fit vital registration data corrected for misclassification of HIV deaths. In generalised epidemics, we minimised a loss function to select epidemic curves most consistent with prevalence data and demographic data for all-cause mortality. We analysed counterfactual scenarios for HIV to assess years of life saved through prevention of mother-to-child transmission (PMTCT) and ART. For tuberculosis, we analysed vital registration and verbal autopsy data to estimate mortality using cause of death ensemble modelling. We analysed data for corrected case-notifications, expert opinions on the case-detection rate, prevalence surveys, and estimated cause-specific mortality using Bayesian meta-regression to generate consistent trends in all parameters. We analysed malaria mortality and incidence using an updated cause of death database, a systematic analysis of verbal autopsy validation studies for malaria, and recent studies (2010-13) of incidence, drug resistance, and coverage of insecticide-treated bednets.Globally in 2013, there were 1·8 million new HIV infections (95% uncertainty interval 1·7 million to 2·1 million), 29·2 million prevalent HIV cases (28·1 to 31·7), and 1·3 million HIV deaths (1·3 to 1·5). At the peak of the epidemic in 2005, HIV caused 1·7 million deaths (1·6 million to 1·9 million). Concentrated epidemics in Latin America and eastern Europe are substantially smaller than previously estimated. Through interventions including PMTCT and ART, 19·1 million life-years (16·6 million to 21·5 million) have been saved, 70·3% (65·4 to 76·1) in developing countries. From 2000 to 2011, the ratio of development assistance for health for HIV to years of life saved through intervention was US$4498 in developing countries. Including in HIV-positive individuals, all-form tuberculosis incidence was 7·5 million (7·4 million to 7·7 million), prevalence was 11·9 million (11·6 million to 12·2 million), and number of deaths was 1·4 million (1·3 million to 1·5 million) in 2013. In the same year and in only individuals who were HIV-negative, all-form tuberculosis incidence was 7·1 million (6·9 million to 7·3 million), prevalence was 11·2 million (10·8 million to 11·6 million), and number of deaths was 1·3 million (1·2 million to 1·4 million). Annualised rates of change (ARC) for incidence, prevalence, and death became negative after 2000. Tuberculosis in HIV-negative individuals disproportionately occurs in men and boys (versus women and girls); 64·0% of cases (63·6 to 64·3) and 64·7% of deaths (60·8 to 70·3). Globally, malaria cases and deaths grew rapidly from 1990 reaching a peak of 232 million cases (143 million to 387 million) in 2003 and 1·2 million deaths (1·1 million to 1·4 million) in 2004. Since 2004, child deaths from malaria in sub-Saharan Africa have decreased by 31·5% (15·7 to 44·1). Outside of Africa, malaria mortality has been steadily decreasing since 1990.Our estimates of the number of people living with HIV are 18·7% smaller than UNAIDS's estimates in 2012. The number of people living with malaria is larger than estimated by WHO. The number of people living with HIV, tuberculosis, or malaria have all decreased since 2000. At the global level, upward trends for malaria and HIV deaths have been reversed and declines in tuberculosis deaths have accelerated. 101 countries (74 of which are developing) still have increasing HIV incidence. Substantial progress since the Millennium Declaration is an encouraging sign of the effect of global action.Bill & Melinda Gates Foundation.

Abstract

In 2010, overweight and obesity were estimated to cause 3·4 million deaths, 3·9% of years of life lost, and 3·8% of disability-adjusted life-years (DALYs) worldwide. The rise in obesity has led to widespread calls for regular monitoring of changes in overweight and obesity prevalence in all populations. Comparable, up-to-date information about levels and trends is essential to quantify population health effects and to prompt decision makers to prioritise action. We estimate the global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013.We systematically identified surveys, reports, and published studies (n=1769) that included data for height and weight, both through physical measurements and self-reports. We used mixed effects linear regression to correct for bias in self-reports. We obtained data for prevalence of obesity and overweight by age, sex, country, and year (n=19,244) with a spatiotemporal Gaussian process regression model to estimate prevalence with 95% uncertainty intervals (UIs).Worldwide, the proportion of adults with a body-mass index (BMI) of 25 kg/m(2) or greater increased between 1980 and 2013 from 28·8% (95% UI 28·4-29·3) to 36·9% (36·3-37·4) in men, and from 29·8% (29·3-30·2) to 38·0% (37·5-38·5) in women. Prevalence has increased substantially in children and adolescents in developed countries; 23·8% (22·9-24·7) of boys and 22·6% (21·7-23·6) of girls were overweight or obese in 2013. The prevalence of overweight and obesity has also increased in children and adolescents in developing countries, from 8·1% (7·7-8·6) to 12·9% (12·3-13·5) in 2013 for boys and from 8·4% (8·1-8·8) to 13·4% (13·0-13·9) in girls. In adults, estimated prevalence of obesity exceeded 50% in men in Tonga and in women in Kuwait, Kiribati, Federated States of Micronesia, Libya, Qatar, Tonga, and Samoa. Since 2006, the increase in adult obesity in developed countries has slowed down.Because of the established health risks and substantial increases in prevalence, obesity has become a major global health challenge. Not only is obesity increasing, but no national success stories have been reported in the past 33 years. Urgent global action and leadership is needed to help countries to more effectively intervene.Bill & Melinda Gates Foundation.

Abstract

The implementation of comprehensive smoke-free laws has been associated with reductions in second-hand smoke exposure at home in several high income countries. There is little information on whether these benefits extend to low income and middle income countries with a growing tobacco-related disease burden such as India.State and individual-level analysis of cross-sectional data from the Global Adult Tobacco Survey India, 2009/2010. Associations between working in a smoke-free indoor environment and living in a smoke-free home were examined using correlation at the state level, and multivariate logistic regression at the individual level.The percentage of respondents employed indoors (outside the home) working in smoke-free environments who lived in a smoke-free home was 64.0% compared with 41.7% of those who worked where smoking occurred. Indian states with higher proportions of smoke-free workplaces had higher proportions of smoke-free homes (rs=0.54, p<0.005). In the individual-level analysis, working in a smoke-free workplace was associated with a significantly higher likelihood of living in a smoke-free home (adjusted OR=2.07; 95% CI 1.64 to 2.52) after adjustment for potential confounders.Implementation of smoke-free legislation in India was associated with a higher proportion of adults reporting a smoke-free home. These findings further strengthen the case for accelerated implementation of Article 8 of the Framework Convention on Tobacco Control (FCTC) in low and middle income countries.

Abstract

We combined a metabolic and an epidemiological model of obesity to estimate changes in calorie intake and physical activity necessary to achieve the Healthy People 2020 objective of reducing adult obesity prevalence from 33.9% to 30.5%.We used the National Health and Nutrition Examination Survey (1999-2010) to construct and validate a microsimulation model of the US population aged 10 years and older, for 2010 to 2020.Obesity prevalence is expected to shift toward older adults, and disparities are expected to widen between White, higher-income groups and minority, lower-income groups if recent calorie consumption and expenditure trends continue into the future. Although a less than 10% reduction in daily calorie intake or increase in physical activity would in theory achieve the Healthy People 2020 objective, no single population-level intervention is likely to achieve the target alone, and individual weight-loss attempts are even more unlikely to achieve the target.Changes in calorie intake and physical activity portend rising inequalities in obesity prevalence. These changes require multiple simultaneous population interventions.

Abstract

Unlike other west European countries, there is a long-term trend of rising alcohol consumption and mortality in England. Whether drinking will rise or fall during the current recession is widely debated. We examined how the recession affected alcohol use in adults in England using individual-level data.We analysed a nationally representative sample of non-institutionalized white persons aged 20-60 years from seven waves of the Health Survey for England, 2004-2010 (n = 36 525), to assess trends in alcohol use and frequency before, during and after the recession and in association with unemployment, correcting for possible changes in sample composition and socio-demographic confounders. The primary analysis compared 2006/7 with 2008/9, following the official onset of the UK recession in early 2008.During England's recession, there was a significant decrease in frequent drinking defined as drinking four or more days in the past week (27.1% in 2006 to 23.9% in 2009, P < 0.001), the number of units of alcohol imbibed on the heaviest drinking day (P < 0.01) and the number of days that individuals reported drinking over the past seven days (P < 0.01). However, among current drinkers who were unemployed there was a significantly elevated risk of binge drinking in 2009 and 2010 (odds ratio = 1.64, 95% confidence interval: 1.22-2.19, P = 0.001) that was not previously observed in 2004-2008 (1.03, 0.76-1.41; test for effect heterogeneity: P = 0.036).England's recession was associated with less hazardous drinking among the population overall, but with rises in binge drinking among a smaller high-risk group of unemployed drinkers.

Abstract

To reduce obesity and type 2 diabetes rates, lawmakers have proposed modifying Supplemental Nutrition Assistance Program (SNAP) benefits to encourage healthier food choices. We examined the impact of two proposed policies: a ban on using SNAP dollars to buy sugar-sweetened beverages; and a subsidy in which for every SNAP dollar spent on fruit and vegetables, thirty cents is credited back to participants' SNAP benefit cards. We used nationally representative data and models describing obesity, type 2 diabetes, and determinants of food consumption among a sample of over 19,000 SNAP participants. We found that a ban on SNAP purchases of sugar-sweetened beverages would be expected to significantly reduce obesity prevalence and type 2 diabetes incidence, particularly among adults ages 18-65 and some racial and ethnic minorities. The subsidy policy would not be expected to have a significant effect on obesity and type 2 diabetes, given available data. Such a subsidy could, however, more than double the proportion of SNAP participants who meet federal vegetable and fruit consumption guidelines.

Abstract

The Global Burden of Diseases, Injuries, and Risk Factors Study 2010 confirms ischemic heart disease and stroke as the leading cause of death and that hypertension is the main associated risk factor worldwide. How best to respond to the rising prevalence of hypertension in resource-deprived settings is a topic of ongoing public-health debate and discussion. In low-income and middle-income countries, socioeconomic inequality and cultural factors play a role both in the development of risk factors and in the access to care. In Europe, cultural barriers and poor communication between health systems and migrants may limit migrants from receiving appropriate prevention, diagnosis, and treatment. To use more efficiently resources available and to make treatment cost-effective at the patient level, cardiovascular risk approach is now recommended. In 2011, The European Society of Hypertension established a Working Group on 'Hypertension and Cardiovascular risk in low resource settings', which brought together cardiologists, diabetologists, nephrologists, clinical trialists, epidemiologists, economists, and other stakeholders to review current strategies for cardiovascular risk assessment in population studies in low-income and middle-income countries, their limitations, possible improvements, and future interests in screening programs. This report summarizes current evidence and presents highlights of unmet needs.

Abstract

Why have patterns of healthcare spending varied during the Great Recession? Using cross-national, harmonised data for 27 EU countries from 1995 to 2011, we evaluated political, economic, and health system determinants of recent changes to healthcare expenditure. Data from EuroStat, the IMF, and World Bank (2013 editions) were evaluated using multivariate random- and fixed-effects models, correcting for pre-existing time-trends. Reductions in government health expenditure were not significantly associated with magnitude of economic recessions (annual change in GDP, p=0.31, or cumulative decline, p=0.40 or debt crises (measured by public debt as a percentage of GDP, p=0.38 or per capita, p=0.83)). Nor did ideology of governing parties have an effect. In contrast, each $100 reduction in tax revenue was associated with a $2.72 drop in health spending (95% CI: $1.03-4.41). IMF borrowers were significantly more likely to reduce healthcare budgets than non-IMF borrowers (OR=3.88, 95% CI: 1.95 -7.74), even after correcting for potential confounding by indication. Exposure to lending from international financial institutions, tax revenue falls, and decisions to implement cuts correlate more closely than underlying economic conditions or orientation of political parties with healthcare expenditure change in EU member states.

Abstract

Since late 2010, the Arab world has entered a tumultuous period of change, with populations demanding more inclusive and accountable government. The region is characterised by weak political institutions, which exclude large proportions of their populations from political representation and government services. Building on work in political science and economics, we assess the extent to which the quality of governance, or the extent of electoral democracy, relates to adult, infant, and maternal mortality, and to the perceived accessibility and improvement of health services. We compiled a dataset from the World Bank, WHO, Institute for Health Metrics and Evaluation, Arab Barometer Survey, and other sources to measure changes in demographics, health status, and governance in the Arab World from 1980 to 2010. We suggest an association between more effective government and average reductions in mortality in this period; however, there does not seem to be any relation between the extent of democracy and mortality reductions. The movements for changing governance in the region threaten access to services in the short term, forcing migration and increasing the vulnerability of some populations. In view of the patterns observed in the available data, and the published literature, we suggest that efforts to improve government effectiveness and to reduce corruption are more plausibly linked to population health improvements than are efforts to democratise. However, these patterns are based on restricted mortality data, leaving out subjective health metrics, quality of life, and disease-specific data. To better guide efforts to transform political and economic institutions, more data are needed for health-care access, health-care quality, health status, and access to services of marginalised groups.

Abstract

Several public health groups have called for the creation of a global fund for 'social protection'-a fund that produces the international equivalent of domestic tax collection and safety net systems to finance care for the ill and disabled and related health costs. All participating countries would pay into a global fund based on a metric of their ability to pay and withdraw from the common pool based on a metric of their need for funds. We assessed how alternative strategies and metrics by which to operate such a fund would affect its size and impact on health system financing. Using a mathematical model, we found that common targets for health funding in low-income countries require higher levels of aid expenditures than presently distributed. Some mechanisms exist that may incentivize reduction of domestic health inequalities, and direct most funds towards the poorest populations. Payments from high-income countries are also likely to decrease over time as middle-income countries' economies grow.

Abstract

Taxing sugar-sweetened beverages (SSBs) has been proposed in high-income countries to reduce obesity and type 2 diabetes. We sought to estimate the potential health effects of such a fiscal strategy in the middle-income country of India, where there is heterogeneity in SSB consumption, patterns of substitution between SSBs and other beverages after tax increases, and vast differences in chronic disease risk within the population.Using consumption and price variations data from a nationally representative survey of 100,855 Indian households, we first calculated how changes in SSB price alter per capita consumption of SSBs and substitution with other beverages. We then incorporated SSB sales trends, body mass index (BMI), and diabetes incidence data stratified by age, sex, income, and urban/rural residence into a validated microsimulation of caloric consumption, glycemic load, overweight/obesity prevalence, and type 2 diabetes incidence among Indian subpopulations facing a 20% SSB excise tax. The 20% SSB tax was anticipated to reduce overweight and obesity prevalence by 3.0% (95% CI 1.6%-5.9%) and type 2 diabetes incidence by 1.6% (95% CI 1.2%-1.9%) among various Indian subpopulations over the period 2014-2023, if SSB consumption continued to increase linearly in accordance with secular trends. However, acceleration in SSB consumption trends consistent with industry marketing models would be expected to increase the impact efficacy of taxation, averting 4.2% of prevalent overweight/obesity (95% CI 2.5-10.0%) and 2.5% (95% CI 1.0-2.8%) of incident type 2 diabetes from 2014-2023. Given current consumption and BMI distributions, our results suggest the largest relative effect would be expected among young rural men, refuting our a priori hypothesis that urban populations would be isolated beneficiaries of SSB taxation. Key limitations of this estimation approach include the assumption that consumer expenditure behavior from prior years, captured in price elasticities, will reflect future behavior among consumers, and potential underreporting of consumption in dietary recall data used to inform our calculations.Sustained SSB taxation at a high tax rate could mitigate rising obesity and type 2 diabetes in India among both urban and rural subpopulations. Please see later in the article for the Editors' Summary.

Six concerns about the data in aid debates: applying an epidemiological perspective to the analysis of aid effectiveness in health and developmentHEALTH POLICY AND PLANNINGStuckler, D., McKee, M., Basu, S.2013; 28 (8): 871-883

Abstract

Is aid helping, hindering, or having no effect on development and health? The answer to this question is highly contested, with proponents on all sides adhering strongly to their competing interpretations. We ask how it is possible for those who are often using the same data to hold such divergent views. Here, we employ an epidemiological perspective and find that, in many cases, the arguments are characterised by methodological weaknesses. There may be selective citation of results and failure to account for bias and confounding, such as where an extraneous factor influencing the outcome is correlated with increased aid or, in confounding by indication, where increased aid is a consequence of a country being in an especially adverse situation. Studies may also lack external validity, whereby lack of data (a widespread problem) or similar considerations mean that analyses are undertaken on an unrepresentative subset of countries. Multiple outcome measures can also be problematic, where the main outcome of interest is not specified in advance. Many studies fail to account for differential time lags between changes in aid and the outcomes being studied. Some studies may also be underpowered to detect an association where one exists. Although, ideally, this debate should be informed by large scale randomised controlled trials, this will often be unfeasible. Given this limitation, it is essential that those engaged in it are cognisant of the many methodological issues that face any observational study.

Abstract

Chronic noncommunicable diseases (NCDs) are now prevalent in many low- and middle-income countries and confer a heightened risk of disability. It is unclear how public health programs can identify the older adults at highest risk of disability related to NCDs within diverse developing country populations. We studied nationally representative survey data from 7,150 Indian adults older than 50 years of age who participated in the World Health Organization Study on Global Aging and Adult Health (2007-2010) to identify population subgroups who are highly disabled. Using machine-learning algorithms, we identified sociodemographic correlates of disability. Although having 2 or more symptomatic NCDs was a key correlate of disability, the prevalence of symptomatic, undiagnosed NCDs was highest among the lowest 2 wealth quintiles of Indian adults, contrary to prior hypotheses of increased NCDs with wealth. Women and persons from rural populations were also disproportionately affected by nondiagnosed NCDs, with high out-of-pocket health care expenditures increasing the probability of remaining symptomatic from NCDs. These findings also indicate that NCD prevalence surveillance studies in low- and middle-income countries should expand beyond self-reported diagnoses to include more extensive symptom- and examination-based surveys, given the likely high rate of surveillance bias due to barriers to diagnosis among vulnerable populations.

Abstract

Objectives. We estimated the relationship between soft drink consumption and obesity and diabetes worldwide. Methods. We used multivariate linear regression to estimate the association between soft drink consumption and overweight, obesity, and diabetes prevalence in 75 countries, controlling for other foods (cereals, meats, fruits and vegetables, oils, and total calories), income, urbanization, and aging. Data were obtained from the Euromonitor Global Market Information Database, the World Health Organization, and the International Diabetes Federation. Bottled water consumption, which increased with per-capita income in parallel to soft drink consumption, served as a natural control group. Results. Soft drink consumption increased globally from 9.5 gallons per person per year in 1997 to 11.4 gallons in 2010. A 1% rise in soft drink consumption was associated with an additional 4.8 overweight adults per 100 (adjusted B; 95% confidence interval [CI]?=?3.1, 6.5), 2.3 obese adults per 100 (95% CI?=?1.1, 3.5), and 0.3 adults with diabetes per 100 (95% CI?=?0.1, 0.8). These findings remained robust in low- and middle-income countries. Conclusions. Soft drink consumption is significantly linked to overweight, obesity, and diabetes worldwide, including in low- and middle-income countries. (Am J Public Health. Published online ahead of print March 14, 2013: e1-e7. doi:10.2105/AJPH.2012.300974).

Social Epidemiology of Hypertension in Middle-Income Countries: Determinants of Prevalence, Diagnosis, Treatment, and Control in the WHO SAGE Study.HypertensionBasu, S., Millett, C.2013; 62 (1): 18-26

Abstract

Large-scale hypertension screening campaigns have been recommended for middle-income countries. We sought to identify sociodemographic predictors of hypertension prevalence, diagnosis, treatment, and control among middle-income countries. We analyzed data from 47 443 adults in all 6 middle-income countries (China, Ghana, India, Mexico, Russia, and South Africa) sampled in nationally representative household assessments from 2007 to 2010 as part of the World Health Organization Study on Global Aging and Adult Health. We estimated regression models accounting for age, sex, urban/rural location, nutrition, and obesity, as well as hypothesized covariates of healthcare access, such as income and insurance. Hypertension prevalence varied from 23% (India) to 52% (Russia), with between 30% (Russia) and 83% (Ghana) of hypertensives undiagnosed before the survey and between 35% (Russia) and 87% (Ghana) untreated. Although the risk of hypertension significantly increased with age (odds ratio, 4.6; 95% confidence interval, 3.0-7.1; among aged, 60-79 versus <40 years), the risk of being undiagnosed or untreated fell significantly with age. Obesity was a significant correlate to hypertension (odds ratio, 3.7; 95% confidence interval, 2.1-6.8 for obese versus normal weight), and was prevalent even among the lowest income quintile (13% obesity). Insurance status and income also emerged as significant correlates to diagnosis and treatment probability, respectively. More than 90% of hypertension cases were uncontrolled, with men having 3 times the odds as women of being uncontrolled. Overall, the social epidemiology of hypertension in middle-income countries seems to be correlated to increasing obesity prevalence, and hypertension control rates are particularly low for adult men across distinct cultures.

The Effect of Tobacco Control Measures during a Period of Rising Cardiovascular Disease Risk in India: A Mathematical Model of Myocardial Infarction and StrokePLOS MEDICINEBasu, S., Glantz, S., Bitton, A., Millett, C.2013; 10 (7)

Abstract

We simulated tobacco control and pharmacological strategies for preventing cardiovascular deaths in India, the country that is expected to experience more cardiovascular deaths than any other over the next decade.A microsimulation model was developed to quantify the differential effects of various tobacco control measures and pharmacological therapies on myocardial infarction and stroke deaths stratified by age, gender, and urban/rural status for 2013 to 2022. The model incorporated population-representative data from India on multiple risk factors that affect myocardial infarction and stroke mortality, including hypertension, hyperlipidemia, diabetes, coronary heart disease, and cerebrovascular disease. We also included data from India on cigarette smoking, bidi smoking, chewing tobacco, and secondhand smoke. According to the model's results, smoke-free legislation and tobacco taxation would likely be the most effective strategy among a menu of tobacco control strategies (including, as well, brief cessation advice by health care providers, mass media campaigns, and an advertising ban) for reducing myocardial infarction and stroke deaths over the next decade, while cessation advice would be expected to be the least effective strategy at the population level. In combination, these tobacco control interventions could avert 25% of myocardial infarctions and strokes (95% CI: 17%-34%) if the effects of the interventions are additive. These effects are substantially larger than would be achieved through aspirin, antihypertensive, and statin therapy under most scenarios, because of limited treatment access and adherence; nevertheless, the impacts of tobacco control policies and pharmacological interventions appear to be markedly synergistic, averting up to one-third of deaths from myocardial infarction and stroke among 20- to 79-y-olds over the next 10 y. Pharmacological therapies could also be considerably more potent with further health system improvements.Smoke-free laws and substantially increased tobacco taxation appear to be markedly potent population measures to avert future cardiovascular deaths in India. Despite the rise in co-morbid cardiovascular disease risk factors like hyperlipidemia and hypertension in low- and middle-income countries, tobacco control is likely to remain a highly effective strategy to reduce cardiovascular deaths. Please see later in the article for the Editors' Summary.

Abstract

David Stuckler and Sanjay Basu comment on a study by Carl Lachat and colleagues documenting the lack of policies addressing noncommunicable disease prevention in low- and middle-income countries and outline steps for making such policies accessible, effective, and transparent.

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The aim of this study was to assess changes in alcohol use in the USA during the Great Recession.Drinking participation, drinking frequency, drinking intensity, total alcohol consumption and frequency of binge drinking were assessed in a nationally representative sample of 2,050,431 US women and men aged 18 and older, interviewed between 2006 and 2010.The prevalence of any alcohol use significantly declined during the economic recession, from 52.0% in 2006-2007 to 51.6% in 2008-2009 (P < 0.05), corresponding to 880,000 fewer drinkers (95% confidence interval [CI] 140,000 to 1.6 million). There was an increase, however, in the prevalence of frequent binging, from 4.8% in 2006-2007 to 5.1% in 2008-2009 (P < 0.01), corresponding to 770,000 more frequent bingers (95% CI 390,000 to 1.1 million). Non-Black, unmarried men under 30 years, who recently became unemployed, were at highest risk for frequent binging.During the Great Recession there was an increase in abstention from alcohol and a rise in frequent binging.

Was the Great Depression a cause or correlate of significant mortality declines? An epidemiological response to GranadosJOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTHStuckler, D., Meissner, C., Fishback, P., Basu, S., McKee, M.2013; 67 (5): 467-467

Abstract

The financial crisis in Europe has posed major threats and opportunities to health. We trace the origins of the economic crisis in Europe and the responses of governments, examine the effect on health systems, and review the effects of previous economic downturns on health to predict the likely consequences for the present. We then compare our predictions with available evidence for the effects of the crisis on health. Whereas immediate rises in suicides and falls in road traffic deaths were anticipated, other consequences, such as HIV outbreaks, were not, and are better understood as products of state retrenchment. Greece, Spain, and Portugal adopted strict fiscal austerity; their economies continue to recede and strain on their health-care systems is growing. Suicides and outbreaks of infectious diseases are becoming more common in these countries, and budget cuts have restricted access to health care. By contrast, Iceland rejected austerity through a popular vote, and the financial crisis seems to have had few or no discernible effects on health. Although there are many potentially confounding differences between countries, our analysis suggests that, although recessions pose risks to health, the interaction of fiscal austerity with economic shocks and weak social protection is what ultimately seems to escalate health and social crises in Europe. Policy decisions about how to respond to economic crises have pronounced and unintended effects on public health, yet public health voices have remained largely silent during the economic crisis.

Abstract

Tuberculosis (TB) is characterized by a subclinical phase (symptoms absent or not considered abnormal); prediagnostic phase (symptoms noticed but diagnosis not pursued); and clinical phase (care actively sought). Diagnostic capacity during these phases is limited.To estimate the population-level impact of TB case-finding strategies in the presence of subclinical and prediagnostic disease.We created a mathematical epidemic model of TB, calibrated to global incidence. We then introduced three prototypical diagnostic interventions: increased sensitivity of diagnosis in the clinical phase by 20% ("passive"); early diagnosis during the prediagnostic phase at a rate of 10% per year ("enhanced"); and population-based diagnosis of 5% of undiagnosed prevalent cases per year ("active").If the subclinical phase was ignored, as in most models, the passive strategy was projected to reduce TB incidence by 18% (90% uncertainty range [UR], 11-32%) by year 10, compared with 23% (90% UR, 14-35%) for the enhanced strategy and 18% (90% UR, 11-28%) for the active strategy. After incorporating a subclinical phase into the model, consistent with population-based prevalence surveys, the active strategy still reduced 10-year TB incidence by 16% (90% UR, 11-28%), but the passive and enhanced strategies' impact was attenuated to 11% (90% UR, 8-25%) and 6% (90% UR, 4-13%), respectively. The degree of attenuation depended strongly on the transmission rate during the subclinical phase.Subclinical disease may limit the impact of current diagnostic strategies for TB. Active detection of undiagnosed prevalent cases may achieve greater population-level TB control than increasing passive case detection.

Abstract

While experimental and observational studies suggest that sugar intake is associated with the development of type 2 diabetes, independent of its role in obesity, it is unclear whether alterations in sugar intake can account for differences in diabetes prevalence among overall populations. Using econometric models of repeated cross-sectional data on diabetes and nutritional components of food from 175 countries, we found that every 150 kcal/person/day increase in sugar availability (about one can of soda/day) was associated with increased diabetes prevalence by 1.1% (p <0.001) after testing for potential selection biases and controlling for other food types (including fibers, meats, fruits, oils, cereals), total calories, overweight and obesity, period-effects, and several socioeconomic variables such as aging, urbanization and income. No other food types yielded significant individual associations with diabetes prevalence after controlling for obesity and other confounders. The impact of sugar on diabetes was independent of sedentary behavior and alcohol use, and the effect was modified but not confounded by obesity or overweight. Duration and degree of sugar exposure correlated significantly with diabetes prevalence in a dose-dependent manner, while declines in sugar exposure correlated with significant subsequent declines in diabetes rates independently of other socioeconomic, dietary and obesity prevalence changes. Differences in sugar availability statistically explain variations in diabetes prevalence rates at a population level that are not explained by physical activity, overweight or obesity.

Abstract

Nearly all European countries have been affected by the economic crisis that began in 2007, but the consequences have been among the worst in Spain. We investigated the associations of the recession on the frequency of mood, anxiety, somatoform, alcohol-related and eating disorders among those visiting Spanish primary care settings.Primary care physicians selected randomized samples of patients attending primary care centres representing Spain's consulting populations. A total of 7940 patients in 2006-07 and 5876 in 2010-11 were administered the Primary Care Evaluation of Mental Disorders (PRIME-MD) instrument to diagnose mental disorders. Multivariate logistic regression models were used to quantify overall changes in the frequency of mental disorders, adjusting for potential socio-demographic differences in consulting populations unrelated to economic factors.Compared with the pre-crisis period of 2006, the 2010 survey revealed substantial and significant increases in the proportion of patients with mood (19.4% in major depression), anxiety (8.4% in generalized anxiety disorder), somatoform (7.3%) and alcohol-related disorders (4.6% in alcohol dependence), all significant at P < 0.001, but not in eating disorders (0.15%, P = 0.172). Independent of observed risks of unemployment [odds ratio (OR) = 1.72, P < 0.001], we observed a significantly elevated risk of major depression associated with mortgage repayment difficulties (OR = 2.12, P < 0.001) and evictions (OR = 2.95, P < 0.001). About one-third of the overall risk in the consulting population's attendance with mental health disorders could be attributed to the combined risks of household unemployment and mortgage payment difficulties.Recession has significantly increased the frequency of mental health disorders and alcohol abuse among primary care attendees in Spain, particularly among families experiencing unemployment and mortgage payment difficulties.

Abstract

During the 1990s, Italy privatised a significant portion of its healthcare delivery. The authors compared the effectiveness of private and public sector healthcare delivery in reducing avoidable mortality (deaths that should not occur in the presence of effective medical care).The authors calculated the average rate of change in age-standardised avoidable mortality rates in 19 of Italy's regions from 1993 to 2003. Multivariate regression models were used to analyse the relationship between rates of change in avoidable mortality and levels of spending on public versus private healthcare delivery, controlling for potential demographic and economic confounders.Greater spending on public delivery of health services corresponded to faster reductions in avoidable mortality rates. Each ?100 additional public spending per capita on NHS delivery was independently associated with a 1.47% reduction in the rate of avoidable mortality (p=0.003). In contrast, spending on private sector services had no statistically significant effect on avoidable mortality rates (p=0.557). A higher percentage of spending on private sector delivery was associated with higher rates of avoidable mortality (p=0.002). The authors found that neither public nor private sector delivery spending was significantly associated with non-avoidable mortality rates, plausibly because non-avoidable mortality is insensitive to healthcare services.Public spending was significantly associated with reductions in avoidable mortality rates over time, while greater private sector spending was not at the regional level in Italy.

Abstract

Ageing and urbanization leading to sedentary lifestyles have been the major explanations proposed for a dramatic rise in diabetes worldwide and have been the variables used to predict future diabetes rates. However, a transition to Western diets has been suggested as an alternative driver. We sought to determine what socio-economic and dietary factors are the most significant population-level contributors to diabetes prevalence rates internationally.Multivariate regression models were used to study how market sizes of major food products (sugars, cereals, vegetable oils, meats, total joules) corresponded to diabetes prevalence, incorporating lagged and cumulative effects. The underlying social determinants of food market sizes and diabetes prevalence rates were also studied, including ageing, income, urbanization, overweight prevalence and imports of foodstuffs.Data were obtained from 173 countries.Population-based survey recipients were the basis for diabetes prevalence and food market data.We found that increased income tends to increase overall food market size among low- and middle-income countries, but the level of food importation significantly shifts the content of markets such that a greater proportion of available joules is composed of sugar and related sweeteners. Sugar exposure statistically explained why urbanization and income have been correlated with diabetes rates.Current diabetes projection methods may estimate future diabetes rates poorly if they fail to incorporate the impact of nutritional factors. Imported sugars deserve further investigation as a potential population-level driver of global diabetes.

Abstract

To examine the potential effect of a tax on palm oil on hyperlipidemia and on mortality due to cardiovascular disease in India.Economic-epidemiologic model.A microsimulation model of mortality due to myocardial infarction and stroke among Indian populations was constructed, incorporating nationally representative data on systolic blood pressure, total cholesterol, tobacco smoking, diabetes, and cardiovascular event history, and stratified by age, sex, and urban/rural residence. Household expenditure data were used to estimate the change in consumption of palm oil following changes in oil price and the potential substitution of alternative oils that might occur after imposition of a tax. A 20% excise tax on palm oil purchases was simulated over the period 2014-23.The model was used to project future mortality due to myocardial infarction and stroke, as well as the potential effect of a tax on food insecurity, accounting for the effect of increased food prices.A 20% tax on palm oil purchases would be expected to avert approximately 363?000 (95% confidence interval 247?000 to 479?000) deaths from myocardial infarctions and strokes over the period 2014-23 in India (1.3% reduction in cardiovascular deaths) if people do not substitute other oils for reduced palm oil consumption. Given estimates of substitution of palm oil with other oils following a 20% price increase for palm oil, the beneficial effects of increased polyunsaturated fat consumption would be expected to enhance the projected reduction in deaths to as much as 421?000 (256?000 to 586?000). The tax would be expected to benefit men more than women and urban populations more than rural populations, given differential consumption and cardiovascular risk. In a scenario incorporating the effect of taxation on overall food expenditures, the tax may increase food insecurity by <1%, resulting in 16?000 (95% confidence interval 12?000 to 22?000) deaths.Curtailing palm oil intake through taxation may modestly reduce hyperlipidemia and cardiovascular mortality, but with potential distributional consequences differentially benefiting male and urban populations, as well as affecting food security.

Abstract

Reducing salt intake has been proposed to prevent cardiovascular disease in India. We sought to determine whether salt reductions would be beneficial or feasible, given the worry that unrealistically large reductions would be required, worsening iodine deficiency and benefiting only urban subpopulations.Future myocardial infarctions (MI) and strokes in India were predicted with a Markov model simulating men and women aged 40 to 69 in both urban and rural locations, incorporating the risk reduction from lower salt intake. If salt intake does not change, we expect ~8.3 million MIs (95% CI: 6.9-9.6 million), 830,000 strokes (690,000-960,000) and 2.0 million associated deaths (1.5-2.4 million) per year among Indian adults aged 40 to 69 over the next three decades. Reducing intake by 3 g/day over 30 years (-0.1 g/year, 25% reduction) would reduce annual MIs by 350,000 (a 4.6% reduction; 95% CI: 320,000-380,000), strokes by 48,000 (-6.5%; 13,000-83,000) and deaths by 81,000 (-4.9%; 59,000-100,000) among this group. The largest decline in MIs would be among younger urban men, but the greatest number of averted strokes would be among rural men, and nearly one-third of averted strokes and one-fifth of averted MIs would be among rural women. Only under a highly pessimistic scenario would iodine deficiency increase (by <0.0001%, ~1600 persons), since inadequate iodized salt access--not low intake of iodized salt--is the major cause of deficiency and would be unaffected by dietary salt reduction.Modest reductions in salt intake could substantially reduce cardiovascular disease throughout India.

Abstract

Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries.Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of "private sector" included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. "Competitive dynamics" for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients.

Abstract

Previous research suggests that the Great Depression led to improvements in public health. However, these studies rely on highly aggregated national data (using fewer than 25 data points) and potentially biased measures of the Great Depression. The authors assess the effects of the Great Depression using city-level estimates of US mortality and an underlying measure of economic crisis, bank suspensions, at the state level.Cause-specific mortalities covering 114 US cities in 36 states between 1929 and 1937 were regressed against bank suspensions and income data from the Federal Deposit Insurance Corporation Database, using dynamic fixed-effects models and adjustments for potential confounding variables.Reductions in all-cause mortalities were mainly attributable to declines in death rates owing to pneumonia (26.4% of total), flu (13.1% of total) and respiratory tuberculosis (11.2% of total), while death rates increased from heart disease (19.4% of total), cancer (8.1% of total) and diabetes (2.9%). Only heart disease can plausibly relate to the contemporaneous economic shocks. The authors found that a higher rate of bank suspensions was significantly associated with higher suicide rates (?=0.32, 95% CI 0.24 to 0.41) but lower death rates from motor-vehicle accidents (?=-0.18, 95% CI -0.29 to -0.07); no significant effects were observed for 30 other causes of death or with a time lag.In contrast with existing research, the authors find that many of the changes in deaths from different causes during the Great Depression were unrelated to economic shocks. Further research is needed to understand the causes of the marked variations in mortality change across cities and states, including the effects of the New Deal and Prohibition.

Abstract

Almost 20% of people smoke tobacco worldwide--a percentage projected to rise in many poor countries. Smoking has been linked to increased individual risk of tuberculosis infection and mortality, but it remains unclear how these risks affect population-wide tuberculosis rates.We constructed a state transition, compartmental, mathematical model of tuberculosis epidemics to estimate the impact of alternative future smoking trends on tuberculosis control. We projected tuberculosis incidence, prevalence, and mortality in each World Health Organization region from 2010 to 2050, and incorporated changing trends in smoking, case detection, treatment success, and HIV prevalence.The model predicted that smoking would produce an excess of 18 million tuberculosis cases (standard error 16-20) and 40 million deaths from tuberculosis (39-41) between 2010 and 2050, if smoking trends continued along current trajectories. The effect of smoking was anticipated to increase the number of tuberculosis cases by 7% (274 million v 256 million) and deaths by 66% (101 million v 61 million), compared with model predictions that did not account for smoking. Smoking was also expected to delay the millennium development goal target to reduce tuberculosis mortality by half from 1990 to 2015. The model estimated that aggressive tobacco control (achieving a 1% decrease in smoking prevalence per year down to eradication) would avert 27 million smoking attributable deaths from tuberculosis by 2050. However, if the prevalence of smoking increased to 50% of adults (as observed in countries with high tobacco use), the model estimated that 34 million additional deaths from tuberculosis would occur by 2050.Tobacco smoking could substantially increase tuberculosis cases and deaths worldwide in coming years, undermining progress towards tuberculosis mortality targets. Aggressive tobacco control could avert millions of deaths from tuberculosis.

Abstract

Despite a tremendous increase in financial resources, many countries are not on track to achieve the child and maternal mortality targets set out in the Millennium Development Goals 4 and 5. It is commonly argued that two main social factors - improved democratic governance and aggregate income - will ultimately lead to progress in reducing child and maternal mortality. However, these two factors alone may be insufficient to achieve progress in settings where there is a high level of social division. To test the effects of growth and democratisation, and their interaction with social inequalities, we regressed data on child and maternal mortality rates for 192 countries against internationally used indexes of income, democracy, and population inequality (including income, ethnic, linguistic, and religious divisions) covering the period 1970-2007. We found that a higher degree of social division, especially ethnic and linguistic fractionalisation, was significantly associated with greater child and maternal mortality rates. We further found that, even in democratic states, greater social division was associated with lower overall population access to healthcare and lesser expansion of health system infrastructure. Perversely, while greater democratisation and aggregate income were associated with reduced maternal and child mortality overall, in regions with high levels of ethnic fragmentation the health benefits of democratisation and rising income were undermined and, at high levels of inequality reversed, so that democracy and growth were adversely related to child and maternal mortality. These findings are consistent with literature suggesting that high degrees of social division in the context of democratisation can strengthen the power of dominant elite and ethnic groups in political decision-making, resulting in health and welfare policies that deprive minority groups (a health-inequality trap). Thus, we show that improving economic growth and democratic governance are insufficient to achieve child and maternal health targets in communities with high levels of persistent social inequality. To reduce child and maternal mortality in highly divided societies, it will be necessary not only to increase growth and promote democratic elections, but also empower disenfranchised communities.

Abstract

There is concern among public health professionals that the current economic downturn, initiated by the financial crisis that started in 2007, could precipitate the transmission of infectious diseases while also limiting capacity for control. Although studies have reviewed the potential effects of economic downturns on overall health, to our knowledge such an analysis has yet to be done focusing on infectious diseases. We performed a systematic literature review of studies examining changes in infectious disease burden subsequent to periods of crisis. The review identified 230 studies of which 37 met our inclusion criteria. Of these, 30 found evidence of worse infectious disease outcomes during recession, often resulting from higher rates of infectious contact under poorer living circumstances, worsened access to therapy, or poorer retention in treatment. The remaining studies found either reductions in infectious disease or no significant effect. Using the paradigm of the "SIR" (susceptible-infected-recovered) model of infectious disease transmission, we examined the implications of these findings for infectious disease transmission and control. Key susceptible groups include infants and the elderly. We identified certain high-risk groups, including migrants, homeless persons, and prison populations, as particularly vulnerable conduits of epidemics during situations of economic duress. We also observed that the long-term impacts of crises on infectious disease are not inevitable: considerable evidence suggests that the magnitude of effect depends critically on budgetary responses by governments. Like other emergencies and natural disasters, preparedness for financial crises should include consideration of consequences for communicable disease control.

Abstract

Official projections of the cholera epidemic in Haiti have not incorporated existing disease trends or patterns of transmission, and proposed interventions have been debated without comparative estimates of their effect. We used a mathematical model of the epidemic to provide projections of future morbidity and mortality, and to produce comparative estimates of the effects of proposed interventions.We designed mathematical models of cholera transmission based on existing models and fitted them to incidence data reported in Haiti for each province from Oct 31, 2010, to Jan 24, 2011. We then simulated future epidemic trajectories from March 1 to Nov 30, 2011, to estimate the effect of clean water, vaccination, and enhanced antibiotic distribution programmes.We project 779,000 cases of cholera in Haiti (95% CI 599,000-914,000) and 11,100 deaths (7300-17,400) between March 1 and Nov 30, 2011. We expect that a 1% per week reduction in consumption of contaminated water would avert 105,000 cases (88,000-116,000) and 1500 deaths (1100-2300). We predict that the vaccination of 10% of the population, from March 1, will avert 63,000 cases (48,000-78,000) and 900 deaths (600-1500). The proposed extension of the use of antibiotics to all patients with severe dehydration and half of patients with moderate dehydration is expected to avert 9000 cases (8000-10,000) and 1300 deaths (900-2000).A decline in cholera prevalence in early 2011 is part of the natural course of the epidemic, and should not be interpreted as indicative of successful intervention. Substantially more cases of cholera are expected than official estimates used for resource allocation. Combined, clean water provision, vaccination, and expanded access to antibiotics might avert thousands of deaths.National Institutes of Health.

Abstract

To test the hypothesis that economic recessions lead to reduced global development assistance for health (DAH).Data obtained from the Creditor Reporting System of the Organisation for Economic Co-operation and Development (OECD) for 15 OECD countries were used to model the percentage change (relative difference) in commitments and disbursements for DAH as a function of three measures of economic recession: recessionary year (as a dummy variable with 0 for no recession and 1 for recession), percentage change in per capita gross domestic product and percentage point change in unemployment rate for recessionary cycles from 1975 through 2007. We looked for an association both during the concurrent recessionary year and one and two years later.No statistically significant association was found in the short or long run between measures of economic recession and the amount of official DAH committed or disbursed.Any important decrease in overall DAH following the current economic recession would have little historical precedent and claims of inevitability would be unjustifiable.

Abstract

We estimated the relationship between mining and tuberculosis (TB) among countries in sub-Saharan Africa.We used multivariate regression to estimate the contribution of mining activity to TB incidence, prevalence, and mortality, as well as rates of TB among people living with HIV, with control for economic, health system, and population confounders.Mining production was associated with higher population TB incidence rates (adjusted b = 0.093; 95% confidence interval [CI] = 0.067, 0.120; with an increase of mining production of 1 SD corresponding to about 33% higher TB incidence or 760,000 more incident cases), after adjustment for economic and population controls. Similar results were observed for TB prevalence and mortality, as well as with alternative measures of mining activity. Independent of HIV, there were significant associations between mining production and TB incidence in countries with high HIV prevalence (? 4% antenatal HIV prevalence; HIV-adjusted B = 0.066; 95% CI = 0.050, 0.082) and between log gold mining production and TB incidence in all studied countries (HIV-adjusted B = 0.053; 95% CI = 0.032, 0.073).Mining is a significant determinant of countrywide variation in TB among sub-Saharan African nations. Comprehensive TB control strategies should explicitly address the role of mining activity and environments in the epidemic.

Abstract

Several recent papers find evidence that global health aid is being diverted to reserves, education, military, or other sectors, and is displacing government spending. This is suggested to occur because ministers of finance have competing, possibly corrupt, priorities and deprive the health sector of resources. Studies have found that development assistance for health routed to governments has a negative impact on health spending and that similar assistance routed to private nongovernmental organizations has a positive impact. An alternative hypothesis is that World Bank and IMF macro-economic policies, which specifically advise governments to divert aid to reserves to cope with aid volatility and keep government spending low, could be causing the displacement of health aid. This article evaluates whether aid displacement was greater when countries undertook a new borrowing program from the IMF between 1996 and 2006. As found in existing studies, for each $1 of development assistance for health, about $0.37 is added to the health system. However, evaluating IMF-borrowing versus non-IMF-borrowing countries reveals that non-borrowers add about $0.45 whereas borrowers add less than $0.01 to the health system. On average, health system spending grew at about half the speed when countries were exposed to the IMF than when they were not. It is important to take account of the political economy of global health finance when interpreting data on financial flows.

Abstract

Public-health priorities are in part driven by fear, yet fear has long been recognized as posing a threat to effective public health interventions. In this article, the authors review the role of fear in global health by focusing on the leading global cause of death and disability: noncommunicable diseases. Taking an historical perspective, first the authors review Samuel Adams' 1911 analysis of the role of fear in generating public health priority and his recommendations about mass educating the public. Next, they show that Adams' analysis still applies today, drawing on contemporary responses to H1N1 and HIV, while illustrating the ongoing neglect of long-term threats such as noncommunicable diseases. Then, they pose the question, "Is it possible, necessary, or useful to create a fear factor for noncommunicable diseases?" After reviewing mixed evidence about the effects of fear on social change (on individual behaviors and on building a mass movement to achieve collective action), the authors conclude by setting out an evidence-based, marketing strategy to generate a sustained, rational response to the noncommunicable disease epidemic.

Health Care Capacity and Allocations Among South Africa's Provinces: Infrastructure-Inequality Traps After the End of ApartheidAMERICAN JOURNAL OF PUBLIC HEALTHStuckler, D., Basu, S., McKee, M.2011; 101 (1): 165-172

Abstract

We assessed the determinants of health care funding allocations among South Africa's provinces and their effects on health care from 1996 through 2007.We performed multivariate regression of funding allocation data against measures of disease burden and health system infrastructure by province.Disease burden was increasingly negatively correlated with funding allocations and explained less than one quarter of the variation in allocations among provinces. Nearly three quarters of the variation in allocations was explained by preexisting hospital infrastructure and health care workers. The density of private hospitals in the preceding year was associated with greater government allocations (b(private) = 0.12; 95% confidence interval [CI] = 0.08, 0.15), but public hospital density in the preceding year was not (b(public) = 0.05; 95% CI = -0.02, 0.11). Greater allocations were associated with a higher number of doctors (b = 0.54; 95% CI = 0.34, 0.75) but fewer nurses (b = -0.37; 95% CI = -0.72,-0.25) in the same year.Regions with a greater capacity to spend funds received more funding and created more infrastructure than those with greater health needs. Historical infrastructure inequalities may have created an infrastructure-inequality trap, in which the distribution of funds to those with greater "absorptive capacity" exacerbates inequalities.

Abstract

Tuberculosis outbreaks originating in prisons, mines, or hospital wards can spread to the larger community. Recent proposals have targeted these high-transmission institutional amplifiers by improving case detection, treatment, or reducing the size of the exposed population. However, what effects these alternative proposals may have is unclear. We mathematically modeled these control strategies and found case detection and treatment methods insufficient in addressing epidemics involving common types of institutional amplifiers. Movement of persons in and out of amplifiers fundamentally altered the transmission dynamics of tuberculosis in a manner not effectively mitigated by detection or treatment alone. Policies increasing the population size exposed to amplifiers or the per-person duration of exposure within amplifiers potentially worsened incidence, even in settings with high rates of detection and treatment success. However, reducing the total population size entering institutional amplifiers significantly lowered tuberculosis incidence and the risk of propagating new drug-resistant tuberculosis strains.

Abstract

Chronic diseases, especially cardiovascular diseases, diabetes, cancer, and chronic obstructive respiratory diseases,are neglected globally despite growing awareness of the serious burden that they cause. Global and national policies have failed to stop, and in many cases have contributed to, the chronic disease pandemic. Low-cost and highly effective solutions for the prevention of chronic diseases are readily available; the failure to respond is now a political, rather than a technical issue. We seek to understand this failure and to position chronic disease centrally on the global health and development agendas. To identify strategies for generation of increased political priority for chronic diseases and to further the involvement of development agencies, we use an adapted political process model. This model has previously been used to assess the success and failure of social movements. On the basis of this analysis,we recommend three strategies: reframe the debate to emphasise the societal determinants of disease and the interrelation between chronic disease, poverty, and development; mobilise resources through a cooperative and inclusive approach to development and by equitably distributing resources on the basis of avoidable mortality; and build one merging strategic and political opportunities, such as the World Health Assembly 2008?13 Action Plan and the high level meeting of the UN General Assembly in 2011 on chronic disease. Until the full set of threats?which include chronic disease?that trap poor households in cycles of debt and illness are addressed, progress towards equitable human development will remain inadequate.

Abstract

Does the current economic crisis require the deep cuts in public spending announced in the June 2010 emergency budget, with potential implications for public health? The arguments for and against such cuts in response to economic recession are complex, but if public health professionals are to engage in debates about future public spending, they should be informed by relevant evidence. In this perspective, we note that opinions among politicians and economists about how to respond to economic downturns are divided, while other EU countries, many with greater levels of debt than the UK, are protecting public expenditure unless required to do so by the International Monetary Fund. Current UK debt may in fact be viewed as sustainable given current information about interest rates, inflation and economic growth. Before accepting large cuts in public spending, it is important to contrast the lack of evidence for such short-term fixes with potentially dire repercussions for population health and welfare.

Abstract

Despite findings indicating that both national income level and income inequality are each determinants of public health, few have studied how national income level, poverty and inequality interact with each other to influence public health outcomes. We analyzed the relationship between gross domestic product (GDP) per capita in purchasing power parity, extreme poverty rates, the gini coefficient for personal income and three common measures of public health: life expectancy, infant mortality rates, and tuberculosis (TB) mortality rates. Introducing poverty and inequality as modifying factors, we then assessed whether the relationship between GDP and health differed during times of increasing, decreasing, and decreasing or constant poverty and inequality. Data were taken from twenty-two Latin American countries from 1960 to 2007 from the December 2008 World Bank World Development Indicators, World Health Organization Global Tuberculosis Database 2008, and the Socio-Economic Database for Latin America and the Caribbean. Consistent with previous studies, we found increases in GDP have a sizable positive impact on population health. However, the strength of the relationship is powerfully influenced by changing levels of poverty and inequality. When poverty was increasing, greater GDP had no significant effect on life expectancy or TB mortality, and only led to a small reduction in infant mortality rates. When inequality was rising, greater GDP had only a modest effect on life expectancy and infant mortality rates, and no effect on TB mortality rates. In sharp contrast, during times of decreasing or constant poverty and inequality, there was a very strong relationship between increasing GDP and higher life expectancy and lower TB and infant mortality rates. Finally, inequality and poverty were found to exert independent, substantial effects on the relationship between national income level and health. Wealthier is indeed healthier, but how much healthier depends on how increases in wealth are distributed.

Abstract

Many low- and middle-income countries are not on track to reach the public health targets set out in the Millennium Development Goals (MDGs). We evaluated whether differential progress towards health MDGs was associated with economic development, public health funding (both overall and as percentage of available domestic funds), or health system infrastructure. We also examined the impact of joint epidemics of HIV/AIDS and noncommunicable diseases (NCDs), which may limit the ability of households to address child mortality and increase risks of infectious diseases.We calculated each country's distance from its MDG goals for HIV/AIDS, tuberculosis, and infant and child mortality targets for the year 2005 using the United Nations MDG database for 227 countries from 1990 to the present. We studied the association of economic development (gross domestic product [GDP] per capita in purchasing-power-parity), the relative priority placed on health (health spending as a percentage of GDP), real health spending (health system expenditures in purchasing-power-parity), HIV/AIDS burden (prevalence rates among ages 15-49 y), and NCD burden (age-standardised chronic disease mortality rates), with measures of distance from attainment of health MDGs. To avoid spurious correlations that may exist simply because countries with high disease burdens would be expected to have low MDG progress, and to adjust for potential confounding arising from differences in countries' initial disease burdens, we analysed the variations in rates of change in MDG progress versus expected rates for each country. While economic development, health priority, health spending, and health infrastructure did not explain more than one-fifth of the differences in progress to health MDGs among countries, burdens of HIV and NCDs explained more than half of between-country inequalities in child mortality progress (R(2)-infant mortality = 0.57, R(2)-under 5 mortality = 0.54). HIV/AIDS and NCD burdens were also the strongest correlates of unequal progress towards tuberculosis goals (R(2) = 0.57), with NCDs having an effect independent of HIV/AIDS, consistent with micro-level studies of the influence of tobacco and diabetes on tuberculosis risks. Even after correcting for health system variables, initial child mortality, and tuberculosis diseases, we found that lower burdens of HIV/AIDS and NCDs were associated with much greater progress towards attainment of child mortality and tuberculosis MDGs than were gains in GDP. An estimated 1% lower HIV prevalence or 10% lower mortality rate from NCDs would have a similar impact on progress towards the tuberculosis MDG as an 80% or greater rise in GDP, corresponding to at least a decade of economic growth in low-income countries.Unequal progress in health MDGs in low-income countries appears significantly related to burdens of HIV and NCDs in a population, after correcting for potentially confounding socioeconomic, disease burden, political, and health system variables. The common separation between NCDs, child mortality, and infectious syndromes among development programs may obscure interrelationships of illness affecting those living in poor households--whether economic (e.g., as money spent on tobacco is lost from child health expenditures) or biological (e.g., as diabetes or HIV enhance the risk of tuberculosis).

Abstract

Many of the Millennium Development Goals are not being achieved in the world's poorest countries, yet only five years remain until the target date. The financing of these Goals is not merely insufficient; current evidence indicates that the temporary nature of the financing, as well as challenges to coordinating its delivery and directing it to the most needy recipients, hinder achievement of the Goals in countries that may benefit most. Traditional approaches to providing development assistance for health have not been able to address both prevalent and emergent public health challenges captured in the Goals; these challenges demand sustained forms of financial redistribution through a coordinated mechanism. A global social health protection fund is proposed to address recurring failures in the modern aid distribution mechanism. Such a Fund could use established and effective strategies for aid delivery to mitigate many financial problems currently undermining the Millennium Development Goals initiative.

Abstract

The International Monetary Fund's recent claims concerning its impact on public health are evaluated against available data. First, the IMF claims that health spending either does not change or increases with IMF-supported programs, but there is substantial evidence to the contrary. Second, the IMF claims to have relaxed strict spending requirements in response to the 2008-9 financial crisis, but there is no evidence supporting this claim, and some limited evidence from the Center for Economic Policy Research contradicting it. Third, the IMF states that wage ceilings on public health are no longer part of its explicit conditionalities to poor countries, as governments can choose how to achieve public spending targets; but in practice, ministers are left with few viable alternatives than to reduce health budgets to achieve specific IMF-mandated targets, so the result effectively preserves former policy. Fourth, the IMF's claim that it has increased aid to poor countries also seems to be contradicted by its policies of diverting aid to reserves, as well as evidence that a very small fraction of the Fund's new lending in response to the financial crisis has reached poor countries. Finally, the IMF's claim that it follows public health standards in tobacco control contrasts with its existing policies, which fail to follow the guidelines recommended by the World Bank and World Health Organization. The authors recommend that the IMF (1) become more transparent in its policies, practices, and data to allow improved independent evaluations of its impact on public health (including Health Impact Assessment) and (2) review considerable public health evidence indicating a negative association between its current policies and public health outcomes.

Abstract

While primary care, obstetrical, and surgical services have started to expand in the world's poorest regions, there is only sparse literature on the essential support systems that are required to make these operations function. Diagnostic imaging is critical to effective rural healthcare delivery, yet it has been severely neglected by the academic, public, and private sectors. Currently, a large portion of the world's population lacks access to any form of diagnostic imaging. In this paper we argue that two primary imaging modalities--diagnostic ultrasound and X-Ray--are ideal for rural healthcare services and should be scaled-up in a rapid and standardized manner. Such machines, if designed for resource-poor settings, should a) be robust in harsh environmental conditions, b) function reliably in environments with unstable electricity, c) minimize radiation dangers to staff and patients, d) be operable by non-specialist providers, and e) produce high-quality images required for accurate diagnosis. Few manufacturers are producing ultrasound and X-Ray machines that meet the specifications needed for rural healthcare delivery in resource-poor regions. A coordinated effort is required to create demand sufficient for manufacturers to produce the desired machines and to ensure that the programs operating them are safe, effective, and financially feasible.

Abstract

What will the current economic crisis mean for the health of the people of Northern Ireland? We review the experience of three major economic crises in the 20(th) century: the Great Depression (1929), the Post-communist Depression (early 1990 s) and the East Asian financial crisis (late 1990 s). Available evidence suggests that health is at risk in times of rapid economic change, in both booms and busts. However the impact on mortality is exacerbated where people have easy access to the means to harm themselves and is ameliorated by the presence of strong social cohesion and social protection systems. On this basis, Northern Ireland may escape relatively unscathed in the short term but as every crisis also provides an opportunity, this is an appropriate time for the Northern Ireland Executive to reflect on whether they are making a sufficient investment in the long term health of their population.

Abstract

There is widespread concern that the present economic crisis, particularly its effect on unemployment, will adversely affect population health. We investigated how economic changes have affected mortality rates over the past three decades and identified how governments might reduce adverse effects.We used multivariate regression, correcting for population ageing, past mortality and employment trends, and country-specific differences in health-care infrastructure, to examine associations between changes in employment and mortality, and how associations were modified by different types of government expenditure for 26 European Union (EU) countries between 1970 and 2007.We noted that every 1% increase in unemployment was associated with a 0.79% rise in suicides at ages younger than 65 years (95% CI 0.16-1.42; 60-550 potential excess deaths [mean 310] EU-wide), although the effect size was non-significant at all ages (0.49%, -0.04 to 1.02), and with a 0.79% rise in homicides (95% CI 0.06-1.52; 3-80 potential excess deaths [mean 40] EU-wide). By contrast, road-traffic deaths decreased by 1.39% (0.64-2.14; 290-980 potential fewer deaths [mean 630] EU-wide). A more than 3% increase in unemployment had a greater effect on suicides at ages younger than 65 years (4.45%, 95% CI 0.65-8.24; 250-3220 potential excess deaths [mean 1740] EU-wide) and deaths from alcohol abuse (28.0%, 12.30-43.70; 1550-5490 potential excess deaths [mean 3500] EU-wide). We noted no consistent evidence across the EU that all-cause mortality rates increased when unemployment rose, although populations varied substantially in how sensitive mortality was to economic crises, depending partly on differences in social protection. Every US$10 per person increased investment in active labour market programmes reduced the effect of unemployment on suicides by 0.038% (95% CI -0.004 to -0.071).Rises in unemployment are associated with significant short-term increases in premature deaths from intentional violence, while reducing traffic fatalities. Active labour market programmes that keep and reintegrate workers in jobs could mitigate some adverse health effects of economic downturns.Centre for Crime and Justice Studies, King's College, London, UK; and Wates Foundation (UK).

Abstract

The evolution of Mycobacterium tuberculosis presents several challenges for public health. HIV and resistance to antimycobacterial medications have evolutionary implications for how Mycobacterium tuberculosis will evolve, as these factors influence the host environment and transmission dynamics of tuberculosis strains. We present an evolutionary invasion analysis of tuberculosis that characterizes the direction of tuberculosis evolution in the context of different natural and human-driven selective pressures, including changes in tuberculosis treatment and HIV prevalence. We find that the evolution of tuberculosis virulence can be affected by treatment success rates, the relative transmissibility of emerging strains, the rate of reactivation from latency among hosts, and the life expectancy of hosts. We find that the virulence of tuberculosis strains may also increase as a consequence of rising HIV prevalence, requiring faster case detection strategies in areas where the epidemics of HIV and tuberculosis collide.

Abstract

Extensively drug-resistant tuberculosis (XDR TB) has been detected in most provinces of South Africa, particularly in the KwaZulu-Natal province where several hundred cases have been reported since 2004. We analyzed the transmission dynamics of XDR TB in the region using mathematical models, and observed that nosocomial transmission clusters of XDR TB may emerge into community-based epidemics under the public health conditions of many South African communities. The effective reproductive number of XDR TB in KwaZulu-Natal may be around 2. Intensified community-based case finding and therapy appears critical to curtailing transmission. In the setting of delayed disease presentation and high system demand, improved diagnostic approaches may need to be employed in community-based programs rather than exclusively at tertiary hospitals. Using branching process mathematics, we observed that early, community-based drug-susceptibility testing and effective XDR therapy could help curtail ongoing transmission and reduce the probability of XDR TB epidemics in neighboring territories.

Abstract

Isoniazid preventive treatment (IPT) has been recommended for human immunodeficiency virus (HIV) infected individuals.We used a mathematical model to simulate the benefits and risks of preventive treatment delivered through antiretroviral (ARV) clinics using clinical data from Botswana.Preventive treatment was found to reduce the incidence of tuberculosis (TB) by at least 12 cases per 100000 population per year versus the scenario without such treatment over a 50-year simulation. Isoniazid (INH) resistant TB was observed to increase by <1% per year, even when using pessimistic assumptions about resistance emergence. The use of tuberculin skin testing had little impact as a screening procedure, while secondary treatment was observed to nearly double the impact of a preventive treatment program. Regardless of whether or not preventive treatment was implemented, INH-resistant TB rose in the context of increasing HIV prevalence, but was minimally amplified by preventive treatment itself.IPT programs implemented through ARV clinics may be effective at reducing TB incidence. The resistance contribution of IPT appears unlikely to supersede its overall incidence and mortality benefits.

The production of consumption: addressing the impact of mineral mining on tuberculosis in southern Africa.Globalization and healthBasu, S., Stuckler, D., Gonsalves, G., Lurie, M.2009; 5: 11-?

Abstract

Miners in southern Africa experience incident rates of tuberculosis up to ten times greater than the general population. Migration to and from mines may be amplifying tuberculosis epidemics in the general population.Migration to and from mineral mines contributes to HIV risks and associated tuberculosis incidence. Health and safety conditions within mines also promote the risk of silicosis (a tuberculosis risk factor) and transmission of tuberculosis bacilli in close quarters. In the context of migration, current tuberculosis prevention and treatment strategies often fail to provide sufficient continuity of care to ensure appropriate tuberculosis detection and treatment. Reports from Lesotho and South Africa suggest that miners pose transmission risks to other household or community members as they travel home undetected or inadequately treated, particularly with drug-resistant forms of tuberculosis. Reducing risky exposures on the mines, enhancing the continuity of primary care services, and improving the enforcement of occupational health codes may mitigate the harmful association between mineral mining activities and tuberculosis incidence among affected communities.Tuberculosis incidence appears to be amplified by mineral mining operations in southern Africa. A number of immediately-available measures to improve continuity of care for miners, change recruitment and compensation practices, and reduce the primary risk of infection may critically mitigate the negative association between mineral mining and tuberculosis.

THE INTERNATIONAL MONETARY FUND'S EFFECTS ON GLOBAL HEALTH: BEFORE AND AFTER THE 2008 FINANCIAL CRISISINTERNATIONAL JOURNAL OF HEALTH SERVICESStuckler, D., Basu, S.2009; 39 (4): 771-781

Abstract

In April 2009, the G20 countries committed US $750 billion to the International Monetary Fund (IMF), which has assumed a central role in global economic management. The IMF provides loans to financially ailing countries, but with strict conditions, typically involving a mix of privatization, liberalization, and fiscal austerity programs. These loan conditions have been extremely controversial. In principle, they are designed to help countries balance their books. In practice, they often translate into reductions in social spending, including spending on public health and health care delivery. As more countries are being exposed to IMF policies, there is a need to establish what we know and do not know about the IMF's effects on global health. This article introduces a series in which contributors review the evidence on the relationship between the IMF and public health and discuss potential ways to improve the Fund's effects on health. While more evidence is needed for some regions, there is sufficient evidence to indicate that IMF programs have been significantly associated with weakened health care systems, reduced effectiveness of health-focused development aid, and impeded efforts to control tobacco, infectious diseases, and child and maternal mortality. Reforms are urgently needed to prevent the current wave of IMF programs from further undermining public health in financially ailing countries and limiting progress toward the health Millennium Development Goals.

Integrating epidemiology, psychology, and economics to achieve HPV vaccination targetsPROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICABasu, S., Chapman, G. B., Galvani, A. P.2008; 105 (48): 19018-19023

Abstract

Human papillomavirus (HPV) vaccines provide an opportunity to reduce the incidence of cervical cancer. Optimization of cervical cancer prevention programs requires anticipation of the degree to which the public will adhere to vaccination recommendations. To compare vaccination levels driven by public perceptions with levels that are optimal for maximizing the community's overall utility, we develop an epidemiological game-theoretic model of HPV vaccination. The model is parameterized with survey data on actual perceptions regarding cervical cancer, genital warts, and HPV vaccination collected from parents of vaccine-eligible children in the United States. The results suggest that perceptions of survey respondents generate vaccination levels far lower than those that maximize overall health-related utility for the population. Vaccination goals may be achieved by addressing concerns about vaccine risk, particularly those related to sexual activity among adolescent vaccine recipients. In addition, cost subsidizations and shifts in federal coverage plans may compensate for perceived and real costs of HPV vaccination to achieve public health vaccination targets.

The transmission and control of XDR TB in South Africa: an operations research and mathematical modelling approachEPIDEMIOLOGY AND INFECTIONBasu, S., Galvani, A. P.2008; 136 (12): 1585-1598

Abstract

Extensively drug-resistant tuberculosis (XDR TB) has emerged as a threat to TB control efforts in several high-burden areas, generating international concern. XDR TB is now found in every region of the world, but appears most worrisome in the context of HIV and in resource-limited settings with congregate hospital wards. Here, we examine the emergence and transmission dynamics of the disease, incorporating the mathematical modelling literature related to airborne infection and epidemiological studies related to the operations of TB control programmes in resource-limited settings. We find that while XDR TB may present many challenges in the setting of resource constraints, the central problems highlighted by the emergence of XDR TB are those that have plagued TB programmes for years. These include a slow rate of case detection that permits prolonged infectiousness, the threat of airborne infection in enclosed spaces, the problem of inadequate treatment delivery and treatment completion, and the need to develop health systems that can address the combination of TB and poverty. Mathematical models of TB transmission shed light on the idea that community-based therapy and rapid detection systems may be beneficial in resource-limited settings, while congregate hospital wards are sites for major structural reform.

Abstract

Emerging research suggests that genetically distinct strains of Mycobacterium tuberculosis may modulate the immune system differently. This may be of importance in high-burden settings where > or =1 genetic group of M. tuberculosis confers significant morbidity.A dynamic mathematical model was constructed to evaluate how different degrees of cross-immunity among M. tuberculosis groups could affect epidemics of drug-resistant tuberculosis (TB).Simulated populations with immunogenically distinct TB strain groups experienced a heightened risk of drug-resistant TB, compared with populations without such strain diversity, even when the same rates of case detection and treatment success were achieved. The highest risks of infection were observed in populations in which HIV was prevalent. Drug-resistant strains with very low transmission fitness could still propagate in environments with reduced cross-immunity among different strain groups, even after common targets for case detection and treatment success are reached.It is possible that the propagation of drug-resistant strains could depend not only on the rate of development of resistance and the fitness of the drug-resistant strains but, also, on the diversity of the strains in the region. The risk of infection with drug-resistant strains could be amplified in locations where there is reduced cross-immunity between originating strain groups. This amplification may be most profound during the first few decades of TB treatment expansion.

Abstract

More than one-third of people in the United States with hepatic C virus (HCV) infection pass through the correctional system annually. Data are lacking on outcomes of treatment with pegylated interferon plus ribavirin (PEG-RBV) in correctional settings.During 2002-2006, we analyzed patients in the Connecticut Department of Correction who received PEG-RBV. We assessed the rates of sustained virological response, hospitalization, and use of medications to treat psychiatric disorders and anemia.Of 138 treatment-naive patients referred for treatment, 68 (49%) were approved. Overall, sustained virological response occurred in 47.1% of patients (for HCV genotype 1, 43.1%; for HCV genotypes 2 and 3, 58.8%). Only 9 patients (13%) discontinued treatment because of adverse effects. Multiple regression analysis revealed that not achieving a sustained virological response was correlated with HCV genotype 1 infection plus cirrhosis (adjusted odds ratio, 12.9; 95% confidence interval, 1.1-148) and baseline major depression (adjusted odds ratio, 3.4; 95% confidence interval, 1.01-11.6), but not with HIV infection, a baseline HCV RNA level >or=400,000 IU/mL, or black race. Compared with baseline, the rate of prescription of a new mood stabilizer (2.2 vs. 0.8 prescriptions per person-year) or an opioid (1.8 vs. 0.5 prescriptions per person-year) was higher during treatment, whereas there was no change in the rate of prescription of benzodiazepines and antipsychotic medications.These results support the feasibility and clinical effectiveness of PEG-RBV for the treatment of chronic HCV infection in correctional facilities.

Mass incarceration can explain population increases in TB and multidrug-resistant TB in European and central Asian countriesPROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICAStuckler, D., Basu, S., McKee, M., King, L.2008; 105 (36): 13280-13285

Abstract

Several microlevel studies have pinpointed prisons as an important site for tuberculosis (TB) and multidrug-resistant TB in European and central Asian countries. To date, no comparative analyses have examined whether rises in incarceration rates can account for puzzling differences in TB trends among overall populations. Using longitudinal TB and cross-sectional multidrug-resistant TB data for 26 eastern European and central Asian countries, we examined whether and to what degree increases in incarceration account for differences in population TB and multidrug-resistant TB burdens. We find that each percentage point increase in incarceration rates relates to an increased TB incidence of 0.34% (population attributable risk, 95% C.I.: 0.10-0.58%, P < 0.01), after controlling for TB infrastructure; HIV prevalence; and several surveillance, economic, demographic, and political indicators. Net increases in incarceration account for a 20.5% increase in TB incidence or nearly three-fifths of the average total increase in TB incidence in the countries studied from 1991 to 2002. Although the number of prisoners is a significant determinant of differences in TB incidence and multidrug-resistant TB prevalence among countries, the rate of prison growth is a larger determinant of these outcomes, and its effect is exacerbated but not confounded by HIV. Differences in incarceration rates are a major determinant of differences in population TB outcomes among eastern European and central Asian countries, and treatment expansion alone does not appear to resolve the effect of mass incarceration on TB incidence.

Abstract

Previous studies have indicated that International Monetary Fund (IMF) economic programs have influenced health-care infrastructure in recipient countries. The post-communist Eastern European and former Soviet Union countries experienced relatively similar political and economic changes over the past two decades, and participated in IMF programs of varying size and duration. We empirically examine how IMF programs related to changes in tuberculosis incidence, prevalence, and mortality rates among these countries.We performed multivariate regression of two decades of tuberculosis incidence, prevalence, and mortality data against variables potentially influencing tuberculosis program outcomes in 21 post-communist countries for which comparative data are available. After correcting for confounding variables, as well as potential detection, selection, and ecological biases, we observed that participating in an IMF program was associated with increased tuberculosis incidence, prevalence, and mortality rates by 13.9%, 13.2%, and 16.6%, respectively. Each additional year of participation in an IMF program was associated with increased tuberculosis mortality rates by 4.1%, and each 1% increase in IMF lending was associated with increased tuberculosis mortality rates by 0.9%. On the other hand, we estimated a decrease in tuberculosis mortality rates of 30.7% (95% confidence interval, 18.3% to 49.5%) associated with exiting the IMF programs. IMF lending did not appear to be a response to worsened health outcomes; rather, it appeared to be a precipitant of such outcomes (Granger- and Sims-causality tests), even after controlling for potential political, socioeconomic, demographic, and health-related confounders. In contrast, non-IMF lending programs were connected with decreased tuberculosis mortality rates (-7.6%, 95% confidence interval, -1.0% to -14.1%). The associations observed between tuberculosis mortality and IMF programs were similar to those observed when evaluating the impact of IMF programs on tuberculosis incidence and prevalence. While IMF programs were connected with large reductions in generalized government expenditures, tuberculosis program coverage, and the number of physicians per capita, non-IMF lending programs were not significantly associated with these variables.IMF economic reform programs are associated with significantly worsened tuberculosis incidence, prevalence, and mortality rates in post-communist Eastern European and former Soviet countries, independent of other political, socioeconomic, demographic, and health changes in these countries. Future research should attempt to examine how IMF programs may have related to other non-tuberculosis-related health outcomes.

Abstract

Extensively drug-resistant (XDR) tuberculosis has spread among hospitalised patients in South Africa, but the epidemic-level effect of hospital-based infection control strategies remains unknown. We modelled the plausible effect of rapidly available infection control strategies on the overall course of the XDR tuberculosis epidemic in a rural area of South Africa.We investigated the effect of administrative, environmental, and personal infection control measures on the epidemic trajectory of XDR tuberculosis in the rural community of Tugela Ferry. Assessments were done with a mathematical model incorporating over 2 years of longitudinal inpatient and community-based data. The model simulated inpatient airborne tuberculosis transmission, community tuberculosis transmission, and the effect of HIV and antiretroviral therapy.If no new interventions are introduced, about 1300 cases of XDR tuberculosis are predicted to occur in the area of Tugela Ferry by the end of 2012, more than half of which are likely to be nosocomially transmitted. Mask use alone would avert fewer than 10% of cases in the overall epidemic, but could prevent a large proportion of cases of XDR tuberculosis in hospital staff. The combination of mask use with reduced hospitalisation time and a shift to outpatient therapy could prevent nearly a third of XDR tuberculosis cases. Supplementing this approach with improved ventilation, rapid drug resistance testing, HIV treatment, and tuberculosis isolation facilities could avert 48% of XDR tuberculosis cases (range 34-50%) by the end of 2012. However, involuntary detention could result in an unexpected rise in incidence due to restricted isolation capacity.A synergistic combination of available nosocomial infection control strategies could prevent nearly half of XDR tuberculosis cases, even in a resource-limited setting. XDR tuberculosis transmission will probably continue in the community, indicating the need to develop and implement parallel community-based programmes.

Abstract

Clinicians treating human immunodeficiency virus (HIV)-infected patients with substance use disorders often face the challenge of managing patients' acute or chronic pain conditions while keeping in mind the potential dangers of prescription opiate dependence. In this clinical review, we critically appraise the existing data concerning barriers to appropriate treatment of pain among HIV-infected patients with substance use disorders. We then analyze published studies concerning the choice of pharmacological pain control regimens for acute and chronic pain conditions in HIV-infected patients, keeping in mind HIV-specific issues related to drug interactions and substance use disorders. We summarize this information in the form of flowcharts for physicians approaching HIV-infected patients who present with complaints of pain, providing evidence-based guidance for the structuring of pain management services and for addressing aberrant drug-taking behaviors.

Abstract

Untreated opioid dependence is a major obstacle to the successful treatment and prevention of human immunodeficiency virus (HIV) infection. In this review, we examine the interwoven epidemics of HIV infection and opioid dependence and the emerging role of buprenorphine in improving HIV treatment outcomes among infected individuals, as well as its role in primary and secondary prevention. This article addresses some of the emerging issues about integrating buprenorphine treatment into HIV clinical care settings and the various strategies that must be considered. Specifically, it addresses the role of buprenorphine in improving HIV treatment outcomes through engagement in care, access to antiretroviral therapy and preventive therapies for opportunistic infections, and the potential benefits of and pitfalls in integrating buprenorphine into HIV clinical care settings. We discuss the key research questions regarding buprenorphine in the area of improving HIV treatment outcomes and prevention, including a review of published studies of buprenorphine and antiretroviral treatment and currently ongoing studies, and provide insight into and models for integrating buprenorphine into HIV clinical care settings. Dialogue among practitioners and policy makers in the HIV care and substance abuse communities will facilitate an effective expansion of buprenorphine and ensure that these beneficial outcomes are achieved.

Abstract

Opiate dependence among human immunodeficiency virus (HIV)-infected patients has been associated with negative clinical outcomes, yet few affected patients receive appropriate and coordinated treatment for both conditions. The introduction of buprenorphine maintenance therapy into HIV care settings provides an opportunity for providers to integrate treatment for opiate dependence into their practices. Buprenorphine maintenance therapy has been associated with reductions in opiate use, increased social stability, improved adherence to antiretroviral therapy, and lowered rates of injection drug use. We describe the following 4 models for the integration of buprenorphine maintenance therapy into HIV care: (1) a primary care model, in which the highly active antiretroviral therapy-administering clinician also prescribes buprenorphine; (2) a model that relies on an on-site specialist in addiction medicine or psychiatry to prescribe the buprenorphine; (3) a hybrid model, in which an on-site specialist provides the induction (with or without stabilization phases) and the HIV care provider provides the maintenance phase; and (4) a drug treatment model that provides buprenorphine maintenance therapy services with HIV services in the substance abuse clinic setting. The key barriers against effective integration of buprenorphine maintenance therapy and primary HIV services are discussed, and we suggest several mechanisms to overcome such obstacles.

Abstract

Before introducing an HIV testing protocol into correctional facilities, the unique nature of these environments must be taken into account. We analyze three testing strategies that have been used in correctional settings--mandatory, voluntary, and routine "opt out" testing--and conclude that routine testing is most likely beneficial to inmates, the correctional system, and the outside community. The ethics of pre-release testing, and the issues surrounding segregation, confidentiality, and linking prisoners with community-based care, also play a role in determining how best to establish HIV testing strategies in correctional facilities. Testing must be performed in a manner that is not simply beneficial to public health, but also enhances the safety and health status of individual inmates. Longer-stay prison settings provide ample opportunities not just for testing but also for in-depth counseling, mental health and substance abuse treatment, and antiretroviral therapy. Jails present added complexities because of their shorter stay with respect to prisons, and testing, treatment, and counseling policies must be adapted to these settings.